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TREATIS E 



ON THE 



STRUCTURE, ECONOMY, AND DISEASES 



OF 



THE EAE; 



BEING 

THE ESSAY 

FOR WHICH THE FOTHERGILLIAN GOLD MEDAL WAS AWARDED 
BY THE MEDICAL SOCIETY OF LONDON. 



BY GEORGE PILCHEK, 

u 

LATE LECTURER ON ANATOMY, AND LECTURER ON SURGER5T AT THE THEATRE 

OF ANATOMY AND MEDICINE, WEBB STREET, BOROUGH ; AND 

SENIOR SURGEON TO THE SURREY DISPENSARY. 




■ 



FIRST AMERICAN FROM THE SECOND LONDON EDITION; WITH NOTES. 



$htlaflelpiifa : 

ED. BARRINGTON & GEO. D. HASWELL. 

NEW YORK — J. & H. G. LANGLEY: CHARLESTON, S. C.-WM. H. BERRETT. 

RICHMOND, VA. — SMITH, DRINKER, AND MORRIS. 

LOUISVILLE, KY.— JAMES MAXWELL, JR. 

1843. 






[Entered, according to act of Congress, in the year 1843, by Barrington and 
Hasweli, in the Clerk's office of the District Court for the Eastern District of Penn- 
sylvania.] 



iftK ig 

M / 




PREFACE. 



The following Treatise owes its appearance in print 
to the circumstance of several friends, who perused it 
after the adjudication of the Fothergillian Medal ; ex- 
pressing a wish that it should be given to the public, as 
calculated to supply a desideratum in medical literature. 
Whether that opinion was influenced by partiality, or 
whether the Essay be of value sufficient to justify its 
publication, will be decided by a liberal Profession. 

The account of the Anatomy and Physiology of the Ear 
precedes that of its morbid state, in accordance with the 
conditions imposed by the Council of the Medical Society; 
the different parts, however, are distinct, therefore the 
Members of our Profession, being acquainted with the 
healthy organ, may refer at once to the history of its 
diseases without inconvenience. 

My thanks are due, and are with much gratification 
given, to Mr. Swinburne, Mr. Hemming, and Mr. Ap- 
pleton, to whose pencils I am obliged for the elucida- 
tions; to Mr. Amyot, Mr. Bryant, Mr. Callaway, Mr. 
Liston, Mr. Masterman, Mr. Maurice, Mr. Moore, Mr. 
Rendle, Mr. Sanders, who have furnished me with the 
reports of several interesting cases which have occurred 
in their practice, and which appear in this Essay ; and 
particularly to my colleagues, Mr. Grainger and Mr. 



g PREFACE. 

Barron, for the assistance they have rendered me in 
arranging the sheets for the press, and in their subsequent 
revision. 

GEORGE PILCHER. 

September, 1838. 



A Second Edition having been called for earlier than 
was expected, the Author has been obliged to limit the 
alterations to a few verbal corrections. He has, however, 
taken this first opportunity of appending a concluding 
Summary, and having the whole of the plates re-drawn, 
which he trusts will render the work more deserving 
the approbation already bestowed upon it. 

7, Great George Street, Westminster, 
January, 1842. 



[The Notes to the American edition, in illustration and ex- 
tension of the views of the Author, are designated by the letter 
(a).-] 

January, 1843. 



CONTENTS. 



Introduction 



13 



PART I. 



Chap. I. Sect. 1. General Observations . 


15 


Sect. 2. Division of the Ear .... 


18 


Sect. 3. Vestibule ...... 


19 


Sect. 4. Semicircular Canals . 


23 


Cochlea ...... 


23 


Otolithes and Otoconies . . . 


26 


Sect. 5. Tympanum ..... 


29 


Membrane of the Tympanum 


30 


Eustachian Tube .... 


31 


Ossicula of the Ear 


31 


Sect. 6. External Ear 


34 


Chap. II. Anatomy of the Human Ear 


41 


Sect. 1. Division 


41 


Sect. 2. External Ear .... 


41 


Auricle ..... 


41 


External Auditory Meatus 


46 


Sect. 3. Tympanum . 


48 


Membrane of the Tympanum 


50 


Inner wall of the Tympanum 


52 


Posterior wall of the Tympanum 


53 


Mastoid Cells . . . 


53 


Eustachian Tube 


53 


Ossicula ..... 


54 


Ligaments of the Ossicula . 


57 


Muscles of the Tympanum . 


58 


Sect. 4. Labyrinth .... 


60 


Osseous Labyrinth 


61 


Vestibule .... 


61 


Semicircular Canals 


62 



10 



CONTENTS, 



Chap. II. Sect. 4, Cochlea . . 


PAGE 

62 


Aqueducts of Cotunnus 


65 


Aqueduct of Fallopius 


66 


Internal Auditory Meatus 


66 


Membranous Labyrinth . 


67 


Liquor of the Labyrinth 


68 


Otolithe 


68 


Sect. 5. Nerves of the Ear 


69 


Acoustic Nerve 


69 


Facial Nerve . 


70 


Vidian Nerve .... 


71 


Otic Ganglion . 


72 


Tympanic Plexus 


73 


Arteries of the Ear 


73 


Veins and Lymphatics 


74 


Chap. III. Physiology op Hearing . 


75 


Sect. 1. Sound . . . . 


75 


Divergence of Sound 


76 


Rapidity of Sound . . 


79 


Distance Sound may be heard 


79 


Conductors of Sound 


81 


Reflection of Sound 


83 


Influence of Tubes upon Sound 


87 


Causes of Sound . 


88 


Nodal Points .... 


90 


Undulations of Inflexion 


90 


Stationary Vibrations . 


91 


Influence of Apertures 


92 


Duration of Vibration 


93 


Variation of Sounds 


94 


Resonance of Sounds . 


95 


Sympathy of Sounds 


95 


Sect. 2. Influence of Sound upon the Ear 


97 


Influence of the External Ear . 


97 




rym- 
98 


panum . * . 



Ossicula . . 102 

Air in the Tympanum 104 
Labyrinth , .106 
Nerves . . 109 



PART II. 

On the Abnormal Condition of the Ear 
Development and Malformations of the Ear 



111 
111 



CONTENTS. 1 1 



PAGE 



Development and Malformations of the Auricle . .112 

External Meatus 1 14 

Tympanum . 117 

Ossicula . 117 

Labyrinth . 124 

— Acoustic Nerve 133 



Deaf-Dumbness 133 



PART III. 

On the Diseases op the Ear .... 138 

Chap. I. Otitis . 139 

Sect. 1. Acute Otitis .... 139 

Sect. 2. External Acute Otitis . . . 141 

- of the Auricle . 141 
Meatus . 143 



Kramer's Arrangement . .151 

Sect. 3. Inflammation of the Membrana Tympani 154 

Sect. 4. Internal Otitis . . . . 157 

Inflammation of the Tympanum . .157 

Mucous Engorgement of the Middle Ear 177 

Diagnosis of Diseases of the Middle Ear 179 

Disease of the Tympanum, from diffused 

inflammation through the Eustachian 

Tube 183 

Additional Treatment of Secondary Deaf- 
ness 184 

Sect. 5. Inflammation of the Labyrinth . 185 



Chap. II. Chronic Diseases of the Ear . . . 188 

Sect. 1. External Chronic Otitis . . .189 

Chronic Inflammation of the Auricle . 190 

Of the Meatus .... 191 

1. Ery thematic Chronic Disease . 192 

2. Chronic Inflammation, with Inordinate 

Secretion 196 

3. Polypus, Fungus, Vegetation of the 

Canal 200 

4. Sinus in the Canal . . . 207 

5. Inordinate Ceruminous Secretion 208 

6. Aphthae, or Herpetic Ulcerations . 213 
Sect. 2. Foreign Bodies in the Meatus . 214 

Insects in the Ear . . . .223 



12 CONTENTS. 



PAGE 



Chap. II. Sect. 3. Chronic Inflammation of the Membrana 

Tympani .... 225 

Diagnosis of the Disease . . 230 

Sect. 4. Chronic Inflammation of the Tympanum 233 

Cerebral Disease following Tympanitis- 235 

Deleau's Division of the Lesions of the 

Medical Ear which occasion Deafness 247 

Sect. 5. Chronic Inflammation of the Eustachian 

Tube 248 

Constitutional Treatment of the Disease 253 
Catheterism of the Eustachian tube . 254 
Mr. Neil's Directions for this Operation 257 
Puncturing the Membrana Tympani 259 
Accidents from Catheterism of the Eu- 
stachian Tube . . . . 260 
. On the Use of Air-Douche in the Dia- 
gnosis and Treatment of Diseases of 
the Ear (with Cases), by Mr. Whar- 
ton Jones 260 

Chap. III. Nervous Diseases of the Ear . . 279 

Sect. 1. Excited Functional Derangement of the 

Acoustic Nerve . . .280 

Sect. 2. Torpid Functional Derangement of the 

Acoustic Nerve . . . 282 
Sect. 3. Functional Derangement of the Tym- 
panic Nerves ; Otalgia . . 286 
Conclusion . . . . . . . 290 

Index 297 



DIRECTIONS TO THE BINDER. 

PLATE I TO FACE PAGE 22 

II 25 

III. . . . . . . .26 

IV. 28 

V. . . ■ 32 

VI. ....... 36 

VII. . 38 

VIII 40 

IX 49 

X 74 

XI 77 

XII 129 

XIII. . 204 

XIV 232 

XV 249 

XVI 255 



INTRODUCTION. 



It might have been reasonably anticipated that the 
immense improvements which have been introduced 
into Ophthalmic Surgery by the labours of some of the 
most distinguished members of our profession, would 
have induced the educated practitioner to investigate 
those numerous diseases to which the Ear is obnoxious. 
Such, unhappily for the welfare of mankind, has not 
been the result; and thus it happens that even at the 
present time, in this country at least, Aural Surgery is 
either almost entirely neglected, or for the most part is 
left in the hands of the ignorant empiric. In conse- 
quence, therefore, of what must be considered a derelic- 
tion of duty on the part of English surgeons, the unfor- 
tunate sufferers from these distressing maladies are, in 
many instances, abandoned to their fate, or compelled to 
seek relief from the employment of nostrums which it 
would be but too charitable to regard as being merely 
harmless in their operation. 

It is not too much to affirm, that until the morbid affec- 
tions of the ear be treated according to the general prin- 
ciples of pathology, and more especially until the study 
of these affections be regarded as constituting a necessary 
and essential partof medical education, it would be in vain 
to hope for any considerable extension of the very limited 
knowledge which is at present possessed on this interest- 
ing class of diseases. The Council of the Medical Society 
of London, in selecting as the subject-matter of the Essay 
to which the Fothergillian Medal for the present year 
was to be adjudged, " The Structure, Economy, and Dis- 
eases of the Ear," were doubtless influenced in their 

2 



14 



INTRODUCTION. 



choice by considerations of this nature ; and whatever 
may be the merits of the various treatises written with 
the hope of obtaining the honourable preference of the 
Society, it is evident that the Council, by thus pointedly 
calling the attention of the profession to this question, 
have conferred an obligation of no ordinary amount on 
the community, and have thus judiciously fulfilled the 
benevolent intention of the enlightened and liberal phy- 
sician who committed this important trust to their 
charge. 

The subject proposed is very extensive, and will cer- 
tainly require some powers of condensation to treat it 
fully within the space usually allotted to an Essay. I 
shall, however, prefer risking the charge of being prolix 
or tedious, to omitting what may appear to me as essen- 
tial in the history normal and abnormal of the Ear. I 
cannot hesitate to understand, that reference is made by 
the proposers of the subject exclusively to the human 
Ear; and yet the term " Economy" would justify the 
supposition that the Essayist might be expected to travel 
a short distance into the wide and fertile field of compa- 
rative anatomy, to collect facts tending to elucidate the 
physiology of the human organ. 

I purpose, therefore, in treating this subject, after 
making some general observations upon the sense, to 
take a slight sketch of the development of the organ in 
the animal gradation ; and to dwell particularly upon 
the anatomy of the human Ear. The physiology will 
properly follow the anatomy ; and in discussing this part 
of the subject, I intend to premise the application of 
sound to the Ear, by some general allusions to Acoustics. 
The history of the abnormal condition of the organ, 
including some observations upon its malformations and 
injuries, will constitute the concluding and most import- 
ant part of the Essay. 



PART I. 

GENERAL OBSERVATIONS. 



CHAPTER L — Section I. 

Hearing* is an animal sense, the effect of undulations 
of airs or fluids, or of vibrations of solids upon a special 
nerve, produced through the medium of an apparatus, 
more or less complicated, and by which important per- 
ceptions of the external world are acquired. 

So important is sound in conveying information to the 
sensorium, that some physiologists have ranked the Ear 
higher in utility than the Eye ; but apparently upon in- 
sufficient grounds; for, as this organ is not so generally 
found in the animal series, it would rather seem that 
Hearing is of secondary importance to Vision in procur- 
ing food, and in avoiding danger. Thus, for example, 
many of the molluscaand articulata possess a demonstra- 
ble organ of the latter sense, whereas in but few, as will 
presently be apparent, can any indication of the former 
be detected. In the higher classes of animals, in which 
both organs are perfected, the ratio of comparative utility 
certainly differs in different species ; for while the animal 
of prey seeks his food rather through the assistance of his 
sight and smell than of his hearing, the timid victim has 
its Ear ever upon the alert to catch the slightest sound 
of its approaching enemy, yet* in all instances the palm 
of utility must be yielded to sight, by the operations of 
which the creature becomes acquainted with objects not 



16 



GENERAL OBSERVATIONS 



only at a greater distance, but also far more speedily, and 
far more accurately. 

Although the more extensive existence of vision in the 
animal creation as compared with audition has been ad- 
duced in proof of its greater utility, yet it is not to be 
received as a general conclusion that the greater the im- 
portance of a function, the more universal will be its organ, 
for the reverse is particularly the fact in those of animal 
life. Thus is it found that first, feeling, and secondly, 
smelling, are more generally present in the animal series ; 
perhaps, indeed, it might be assumed, that all undoubted 
animals possess the former of these faculties, and many 
zoophytes, very low in the scale, are directed to their food 
through the medium of their sense of smell. The gene- 
ral arrangement appears to be that the lowest animal pos- 
sesses only the lowest faculties of sense, — and that as 
the higher of these powers are developed, the lower are 
comparatively, though certainly not absolutely, dimi- 
nished in importance. The exception to this generality is 
in the two highest, where we find that sight, the highest 
animal sense, is met with more early and more generally 
than an unequivocal sense of hearing. " 

When, however, we at last turn our attention to man, 
then do we find the importance of hearing most remarka- 
bly augmented, from its intimate connection with speech. 
The human being who has been blind from infancy, would 
doubtless shrink from the idea of exchanging his acute 
hearing for perfect sight ; yet are there few enjoying the 
benefit of both senses, who do not feel that a greater 
amount of happiness is the product of vision than of au- 
dition ; and with a full consciousness of the all-delightful 
and rapid, — and delightful because rapid — interchange 
of thought, by the means of conversation, of the all-pleas- 
ing, all-exhilarating, all-soothing influences of musical 
concord, still must we feel that the deaf man has to be 
thankful that it is not his sight of which he is deprived. 

But when we recollect the melancholy state of insula- 
tion of the deaf and dumb, and remember that deafness 
from birth inflicts upon the individual deprivation of the 
splendid faculty of speech, — and when we recall to our 
minds many blind from their birth who are proficients in 



ON THE EAR. 



17 



music ; who have acquired vast information ; who have 
made considerable progress in the mechanical arts ; even 
sometimes in the more difficult sciences, as exampled in 
a celebrated professor of mathematics, and who thus per- 
form their parts of usefulness in the great machinery of 
society, we are undecided whether to be deprived of sight, 
or of the conjoined faculties of hearing and speech, be the 
greater evil. 

It has been stated in the definition that hearing is an 
impression made upon the auditory nerve, and of this fact 
no doubt exists in the normal condition : yet, it does 
appear that an influence may be communicated to the 
sensorium by vibrating bodies, without the intervention 
of the acoustic apparatus, so similar to hearing, if it be not 
hearing itself, that there would seem to be reason for 
imagining that the mind, ever watchful to perceive the 
properties of surrounding bodies, will receive those per- 
ceptions through the medium of some other sense, when 
that, whose peculiar office it is to convey these especial 
impressions, is deficient normally or abnormally. Thus 
by many comparative physiologists it is believed that most 
insects not furnished with an Ear, hear by their tentacula, 
which is supposed to be evidenced by their avoidance of 
loud sounds, &c. ; and the writer has known a musical 
amateur, though perfectly deaf, enjoy in a high degree 
the sensations produced by a good performance upon a 
church organ. These impressions may rather be attri- 
buted to an augmentation in the sense of feeling ; for 
undulations of the air, so minute as to produce only sound 
to higher beings, may be as readily felt by the more sen- 
sitive organs of the insect, as a rude blast may be by the 
surface of our bodies ; and the varied vibrations of the 
building, or even of the solid earth, may be distinctlyy£/£ 
and appreciated, through the medium of the entire frame, 
but particularly the skeleton, so as to produce a harmo- 
nious impression, whereas under ordinary circumstances 
an indistinct vibratory motion only would be perceived. 
But it may be said, that in these instances the auditory 
nerve is the agent through which the brain is influenced, 
as the nerves distributed to the tentacula may correspond 
partly to the acoustic ; and in the latter case, though the 



18 



GENERAL OBSERVATIONS. 



organ of hearing be itself disorganized, yet the portion of 
its nerve connected with the brain still enjoying its func- 
tion, may receive the impressions above noticed, and con- 
vey them to the sensorium. Thus it becomes possible 
that every animal, however low in the scale of creation, 
may possess a sense of feeling excited by vibrations of 
the fluid or air in which it lives, analogous to true audi- 
tion. 

De Blainville describes Hearing as necessarily con- 
nected with voice and speech, and, therefore, as partaking 
more of the animal character than the other senses, — a 
theory which is doubtless correct when applied to the 
higher classes ; but, as the Ear is found in some articulata, 
and in all fishes, which, wanting lungs, cannot be sup- 
posed to possess voice, it is certain that this sense must 
exist for other purposes than mental communication ; as, 
for example, to warn the individual of the approach of 
danger, or of its prey, and in an especial manner, probably, 
to facilitate the approximation of the sexes, a surmise, 
which is corroborated by the fact, that Hearing is absent 
in those species in which the sexual organs are united 
in the same individual. 



Section II. 

De Blainville, who has probably given to the scientific 
world the most accurate and simple history of the com- 
parative anatomy of the Ear, has made four divisions of 
this apparatus. 

1st. The essential or fundamental portion — the Ves- 
tibule ; 

2d. The part for perfecting Hearing ; the semicircular 
Canals and the Cochlea ; 

3d. The portion occasioning unison and strength in 
sounds, the Tympanum ; 

4th. The accessory part for the reception of the sono- 
rous rays, the External Ear. 

This division, being founded upon the comparative 
development in the animal series, is correct, and is more- 
over eminently useful in studying the economy of the 



VESTIBULE. 1 9 

Ear. It is found, not only that one division is superadded 
to the rest, in accordance with the increased necessity of 
the sense ; but that each division becomes also more com- 
plicated, till it reaches its perfection in the human Ear. 



Section III. 

1st. The essential or fundamental part of the Ear is 
the Vestibule, so named from its position, in the fully de- 
voloped organ between the second and the third divisions. 
It is a membranous sac, varying in size and figure, most 
frequently oval, and comparatively larger, when it exists 
as the entire Ear, than where it only constitutes part of 
a more complicated apparatus. It is contained in a cor- 
responding fibrous, cartilaginous or bony cavity, which 
has an internal orifice for the admission of vessels and 
nerves; and one external for connexion with the vibra- 
ting fluid around, usually denominated the fenestra ova- 
lis ; which last is closed by the sac of the vestibule, some- 
what perhaps there thickened, so as to constitute the 
mernbrana fenestras ovalis. The vestibular sac is vascu- 
lar, and more or less intimately attached to the parietes 
by the periosteum, perichondrium or cellular membrane. 
"Within it is another, or third layer, supporting the fila- 
ments of the acoustic nerve in a very delicate cellular 
tissue. The nervous layer does not line exactly the vas- 
cular, excepting in the simplest varieties : it sometimes, 
for instance, forms a transverse septum, sometimes folds 
floating in the fluid of the vestibule. Between the vas- 
- cular and nervous membranes is contained a humour, 
almost entirely composed of water, butprobably containing 
a minute quantity of albumen, and of saline matter, chiefly 
soda ; it is supposed to be enveloped in a proper transpa- 
rent membrane, as it preserves a determined figure, and 
appears to be smaller than the containing cavity when 
opened ; it is partially suspended by filaments of nerves. 
In this fluid, or upon its surface, is contained a cretaceous 
or osseous body, which also in some cases appears to be 
attached to nervous fibrils. Another fluid is found in the 
vestibule of the more perfect Ears, between the fibrous 



20 



GENERAL OBSERVATIONS. 



or periosteal and vascular membranes ; it is that described 
by Cotunnus, and named after him; it certainly contains 
a trace of albumen and of soda. In consequence of the 
great delicacy of the membranes, and in most instances 
of the minuteness of the whole cavity, these two fluids 
have been confounded together ; and some anatomists 
still doubt their separate existence. 

This description may be generally applied to the ves- 
tibule, but important exceptions are met with both in the 
most simple and in the more complicated Ear. 

The very simplest organ is formed of a vestibule alone, 
and even this is not clearly demonstrated, lower than the 
Crustacea, for if the inferior classes of the order articulata, 
possess an Ear, it has not as yet been discovered. En- 
tomologists, it is true, have attributed the faculty of hear- 
ing to the class insecta, and particularly the arachnoidea, 
give evidences of this sense, which is now generally sup- 
posed to reside in their antennae, though, unfortunately for 
that opinion, spiders, which are supposed to hear the best, 
are not possessed of these peculiar organs. 

Comparetti has not only described the Ear in insects, 
but has given many views of it ; yet as other, later, and, 
as we should imagine, more careful investigators, have 
failed in discovering the organ, although directed to it by 
the account of his previous researches, we are therefore 
almost obliged to conclude, that Comparetti mistook some 
other structure for the Ear, — an error which might rea- 
dily occur on account of the minuteness of the object, and 
especially by a mind fully expecting to meet what it was 
in search of. De Blainville's examinations have led him 
to discover in the grasshopper a very small orifice on 
each side the posterior part of the head, resembling a 
stigma leading to a little sac within ; he asks if this be 
the Ear, or a communication with the trachea, and then 
suggests the possibility of its performing both offices by 
means of a peculiar nerve expanded upon its surface. 

In a Treatise like the present, it can hardly be neces- 
sary to allude further to Comparetti's views, than to no- 
tice that he generally describes the Ear in insects, and 
in some of the cephalapods, as a simple vestibule, having 
the fenestra ovalis communicating with the surrounding 



VESTIBULE. 



21 



medium, whilst in one or two examples, he alludes also 
to pellucid canals communicating with this little sac. 

The author cannot but again repeat his opinion that 
the assumed evidences of Hearing in the numerous tribes 
of insects, and the gasteropods, and, perhaps, in some of 
the still lower orders of mollusca, ought rather to be 
attributed to an exquisite sense of feeling, which faculty 
these animals are known to possess in an astonishing 
degree of perfection. Thus bees are collected into swarms 
by their own buzzings, and by the rattling of iron imple- 
ments, but their ideas apparently are communicated 
through the medium of their delicate antennae, crossed 
over each other in various manners, which thus become 
their organs of speech, as well as of hearing and feel- 
ing : it is probable that the former effects are the result 
of the sonorous vibrations acting upon their organs of 
touch. 

The fundamental organ of Hearing is distinctly seen 
in the Crustacea (Plate I., figs. 1 and 2) : in which ani- 
mals it consists of a simple sac, of a whitish colour, filled 
with fluid, and containing a small cretaceous body ; this 
sac is pierced by the ultimate divisions of the acoustic 
nerve, some filaments of which appear to be attached to 
the rudimentary otolithe. The vestibule, becoming 
gradually smaller outwards and backwards, forms a 
fenestra ovalis, by perforating the shell at the lower sur- 
face of the first joint of the second pair of antennas ; the 
perforation is closed by a thickish white membrane, and 
protected by a little prominence of the shell. Dr. Roget 
describes a striated groove in the vestibule. 

The cephalopods, as the cuttle-fish, nautilus, &c, 
being more especially aquatic, possess an Ear more 
nearly resembling that of fish ; the organ having, as in 
those animals, an immediate communication with the 
surrounding fluid, and being placed at the inferior and 
posterior part of the head ; besides the humour contained 
in the vestibule, there is now found a well-defined creta- 
ceous body of a cruciform shape, adhering to the sac, and 
doubtless required for the purposes of vibration : the 
whole apparatus is contained in a cartilaginous cavity, 
partly occupied by cellular membrane. Projecting from 

3 



22 



GENERAL OBSERVATIONS. 



the surface of this cartilaginous cavity are four or five 
small tubercles of the same structure, in consequence of 
which, the membranous and cartilaginous surfaces being 
in contact only at those points, the vestibule must enjoy 
a degree of vibration corresponding to the aquatic habits 
of the animal. (Plate L, figs. 3 and 4.) 

It is interesting here to notice that even this simple 
Ear is to be found only in connexion with a dense skele- 
ton, the cuttle-fish having a rudimentary cranium : were 
it otherwise, it is to be presumed the vibrations would be 
insufficient to influence the nerve. 

This fundamental part of the Ear constitutes the entire 
organ in the lamprey and the myxine, the lowest orders 
offish ; the former does not appear to possess a cretace- 
ous body, though one is found in the latter. They have 
in common with fishes in general no external auditory 
orifice. 



PLATE I. 

Fig. 1. — Internal view of the simple ear of the Lobster, a. Ves- 
tibule laid open. b. The acoustic nerve passing from 
the Brain to be expanded upon the Membrane of 
the Vestibule. 

Fig. 2. — External view of the same. a. Opening of the Vestibule 
or Fenestra-Ovalis closed by its membrane, and 
defended by a rim of the shell — (as seen from 
beneath). 

Fig. 3. — External view of the Vestibule of the Ear of the 
Cuttle-fish in its cartilaginous case, and supported 
by its ovoid cartilages, with blood-vessels ramifying 
upon it. 

Fig. 4. — The same laid open, showing the acoustic nerve and 
cruciforme otolithe in situ. 

Fig. 5. — Otolithe of the Dog-Fish') 

Fig. 6. . . Salmon 



Fig. 7. . . Cod-Fish )>of the natural size. 

Fig. 8. . . Whiting | 

Fig. 9. . . Brill J 



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SEMICIRCULAR CANALS. 



Section IV. 



23 



2d. The second division, or parts for perfecting hear- 
ing. — The semicircular canals and the cochlea constitute, 
with the vestibule, the Labyrinth, and by De Blainville 
are considered as diverticula or extensions of that essen- 
tial part. 

The Semicircular Canals, named from their shape, 
though they generally form three-fourths at least of a 
circle, are always three in number, and are placed at the 
upper and posterior part of the vestibule, in such a man- 
ner that two are vertical, one anterior and the other pos- 
terior, while the third is horizontal and external ; they 
communicate by both extremities with the vestibule, 
sometimes by six openings, yet generally by five, in con- 
sequence of the two vertical uniting by the posterior crus 
of the superior and the superior crus of the posterior, to 
form a common canal; more rarely there are but four 
openings into the vestibule. These canals are cylindri- 
cal, except at that extremity of each, which may be 
termed the origin, where an enlargement exists, known 
under the name of the ampulla ; this enlargement some- 
times continues into the vestibular sac, but more fre- 
quently it first becomes again contracted. The Semicir- 
cular Canals consist, like the vestibule, of vascular sacs, 
lining fibrous, or cartilaginous, or bony passages; and 
contain within them other membranous tubes, corre- 
sponding in shape but much more contracted, and upon 
which the nervous filaments are largely expanded. 
These latter tubes are termed the membranous semicir- 
cular canals. The Aqua Labyrinth! occupies the space 
between the lining of the bony or cartilaginous canals 
and the membranous canals ; these latter are also filled 
with a perfectly thin and transparent fluid, and in some 
cases, towards the ampullae, chalky matter is likewise 
found. 

The Cochlea, which is very frequently wanting, the 
canals being then the only part of the second division 
added to the vestibule, is thus named from its shape, 
which resembles the shell of the snail : it is situated 



24 



GENERAL OBSERVATIONS. 



anterior and internal to the vestibule, and is a canal 
taking one, two, or three spiral turns : the cochlea is 
sometimes, as in the ' higher animals, divided into two 
passages, termed scalce, by a spiral septum ; under which 
circumstances, one of the divisions communicates with 
the vestibule, the other indirectly with the surrounding 
medium. In structure it corresponds to the rest of the 
labyrinth, in being a cartilaginous or bony canal lined by 
a vascular membrane, which contains the liquor cotunni, 
but it is not usual to find a second membranous tube 
within this fluid, the nerve being expanded upon the 
vascular lining. 

The first distinctly recognised cochlea is met with in 
reptiles and in birds, whose ears very nearly correspond. 
In these creatures it is evidently a slightly curved elon- 
gation of the vestibule, and in the turtle, frog, &c, it is 
without any division ; but in the crocodile, the highest 
of the reptile species, and in birds, a septum extends 
through it, producing a scala vestibuli, and a scala tym- 
pani. In the mammalia the cochlea becomes convoluted 
into a spiral canal, having a septum throughout, except 
at its apex, where a canalis scalarum communis is formed 
for the communication of the two scalse, it thus corre- 
sponds to the general description given above. 

Of the second Division, the Semicircular Canals much 
more generally exist in the animal series than the un- 
doubted Cochlea ; they are the first superadded elabora- 
tion to the simple vestibule, the fundamental part. Thus 
in fishes the organ consists of a vestibule and semicircular 
canals, having a few and not important peculiarities in 
different species, to which very brief allusion may be 
made. In the lower cartilaginous and osseous fishes, the 
whole Ear is contained in the cavity of the skull, on 
either side of, and projecting posteriorly to, the brain, 
immersed in the fluid which so nearly occupies the en- 
tire cavity of their crania, and which is supposed to be 
serum secreted by and occupying the distended cavity 
of the tunica arachnoidea. Under these circumstances 
the fluid of the skull, the chief intention of which appears 
to be to render the head lighter, and hence to regulate 
the specific gravity of the fish, must be the great medium 
through which the vibrations are communicated to the Ear. 




Vzg.2. 




SEiMICIRCULAR CANALS AND COCHLEA. 



25 



In the higher cartilaginous fishes, as the shark, the 
skate, esturgeon, dog-fish, &c, the inner wall of the ves- 
tibule alone projects into the cavity of the skull, and is in 
contact with the tunica arachnoid es, whilst the other sur- 
faces are surrounded by cartilage, which is now enlarged 
into a considerable prominence, to contain the semicir- 
cular canals. In the salmon and superior bony fishes, 
the semicircular canals are contained likewise in cartilage, 
the vestibule projecting into the cavity of the skull. The 
size and development of these structures is upon the whole 
relative to that of the fish, and they may be considered 
large in comparison with the same parts in mammalia. 
The vestibule, which is not divided by membranous par- 
titions, is a little larger than the united mouths of the 
canals at their communication ; it then somewhat sud- 
denly expands into a sacculus vestibidi, in which is con- 
tained the otolithe, osseous or cretaceous, in character, 
and upon which are expanded many nervous filaments 
(Plate II., fig. 2). Weber has pointed out a communica- 
tion between the air-bladder and the vestibule in the 
lower osseous fishes, by which means the former may 
possibly perform somewhat the part of an external Ear. 

De Blainville and many other anatomists have consi- 
dered this sacculus as the rudiment of the cochlea, and 
when it is considered that in the lower reptiles a pouch, 
more or less conical, proceeding from the vestibule, ap- 
pears to be a further elaboration of this sacculus ; that 
in the higher reptiles and in birds, this pouch is still 
further elongated and divided by a septum ; and that 
thus a gradual transition to the convoluted cochlea of the 
mammalia is traced, it must be confessed that there is good 
reason to believe that the supposition is correct. 



PLATE II. 

Fig. 1. — The Semicircular Canals of a species of the Squalus. 

a. The containing Cartilage partly removed. 

b. Do. completely removed. 
Fig. 2. — The ear of the Esturgeon, showing two of the Semi- 
circular Canals (the horizontal being out of view) 
with the Ampullar opening into the Vestibule, and 
the nerves expanded upon them. 



26 GENERAL OBSERVATIONS. 

The otolithe is bony, or rather shell-like, laminated, 
and hard, in the osseous and lower cartilaginous fish, as 
in the plaice, salmon, &c, of which sketches are annexed 
(Plate I., figs. 5, 6, 7, 8); in the higher cartilaginous 
species it is chalky, soft, or pulpy, effervescing in acid : 
in both it is a flattened oval, having a slight groove on 
its upper margin, by which it appears to be in contact 
with, and partially suspended by, the extremities of the 
nerves. In many of the osseous fishes there are two or 
three smaller bodies, suspended in the fluid, instead of 
one larger. Breschet, who first used the term of otolith es, 
has applied that of otoconies to the calcareous matter. 
These bodies vibrating in the fluid, and perhaps striking 
the sides of the vestibule, like the clapper of a bell, must 
very materially increase the influence of sound upon the 
auditory nerve. 

The semicircular canals in fish are of great extent, with 
very minute cavities, rendering their walls thick, and 
thus guarding against too great a degree of oscillation ; 
their ampullae are large, generally contain otolithes, or 
rather otoconies, and receive the principal distribution of 
the nerve. The cartilaginous canals in the skate and 
other higher orders offish, of which sketches are annexed 
(Plates II. and III.), are considerably larger than the con- 
tained membranous canals, the interspace being occupied 
by a fluid ; this arrangement allows a vibration similar . 
to that occurring within the cranium of the lower orders. 

PLATE III. 

Fig. 1. — The Ear of the Thornback. A. Cavity of the 
Cranium ; B. Cerebral Lobes ; C. Optic Lobes ; 
D. Cerebellum ; E. Medulla Oblongata, a. Fifth 
nerve ; b. Acoustic nerve entering the Vestibule ; 
c. Facial nerve ; d. Vestibule; e. Semicircular canals 
exposed in the cartilage ; f. Cartilage composing the 
walls of the cranium. 

Fig. o # — The Ear of the Cod separated from its Cartilaginous 
canals. — a. Sinus communis ; b. Sacculus rotun- 
dus ; c. posterior, d. anterior, and e. external semi- 
circular Canals ; f. Ampullss of the canals ; g. Utri- 
cule of the Sinus communis ; h. Nervous trunk from 
which branches are given to the Sac ? Utricule, and 
Ampulla. 



Plale 3 




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SEMICIRCULAR CANALS. 27 

The skate, and others of the same class, have an inte- 
resting elongation from the upper and inner corner of the 
vestibule, which terminates in a fenestra ovalis, furnished 
with a membrane, and concealed by the skin between 
the eyes ; hence the ears of these animals possess a com- 
munication with the surrounding medium, and are doubt- 
less capable of producing more accurate perceptions. 
The description of the external ear of the skate by the 
first Monro appears to be incorrect, for he mistook the 
orifices of mucous follicles for external openings leading 
to the vestibule. 

The semicircular canals of birds afford an interesting 
peculiarity in the union and decussation of the horizontal 
and posterior canals about their centre ; the canals are 
large, the superior being especially prominent. (Plate IV.) 
Having already alluded to the Cochlea, a few further 
observations will suffice to dismiss this part of our subject. 
As we examine the apparatus in the advancing series, 
we find probably a rudimentary cochlea in the sacculus 
vestibuli offish ; it is certainly found in reptiles, in which 
it is well defined, and in the crocodile and birds it is 
divided into two canalsby a septum, more especially per- 
haps in the nocturnal birds, as the owl. In mammalia 
this appendage is always found, but not with an uniform 
development ; in the whale it possesses but one turn and 
a half, being but rudimentary, wmereas in the guinea-pig 
it has three turns and a half; in the greater number of 
mammalia it forms two and a half as in man, which may 
therefore be considered as the general type/ In amphi- 
bia, reptiles, birds, and mammalia, all which possess the 
next division of the Ear, the tympanum, the labyrinth is 
encased in bone. 

The uses of the second division of the Ear have been 
variously imagined ; a doubt cannot exist that it increases 
the perfection of hearing, probably capacitating the ani- 
mal to appreciate variations in sound, a supposition which 
is supported by the fact that perfect audition corresponds 
in general to the development of the labyrinth, though, as 
noticed above, the guinea-pig may be considered an ex- 
ception, that animal having an extensive cochlea, without 
affording evidence of unusually acute hearing. It has 



28 



GENERAL OBSERVATIONS. 



been asserted that the cochlea is the part of the organ 
appreciating minute and delicate sounds, in fact consti- 
tuting, in higher animals, the musical Ear. It is not, 
however, so well developed in the singing birds as in 
mammalia, although most of the latter do not furnish 
proofs of such appreciation, and it is as well completed in 
the crow as in the nightingale; if it were merely to allow 
vibrations, a simple straight canal would probably answer 
the purpose better. The preceding details, afforded by 
comparative anatomy, evince that the semicircular canals 
are of more importance than the cochlea for simple hear- 
ing, whilst, for increased nicety of distinction, the latter 
is added ; and the conclusion appears to be evident that 
the curiously convoluted and tortuous canals of the laby- 
rinth, by extending the surface for the expansion of the 
nerve and the undulations of the fluid, conduce to the 
greater or less perfection of the impressions ; and the per- 
ceptions of those impressions being entirely mental and 
independent of the external sense, man alone, with his 
fully developed brain, is capable of appreciating, in all 
their extent, impressions, which may be almost if not quite 
as perfectly formed upon the nerve in the labyrinth of 
the higher mammalia. This subject will be again alluded 
to in the section on physiology of hearing. 



PLATE IV. 

Fig. 1. — Dissection of the Turkey's ear, showing — a. The Meatus 
Externus ; b. The Membrana Tympani ; c. The 
Superior, d. the Posterior, and e. the External Semi- 
circular Canals. 

Fig. 2.— Another view, showing — a. The inner surface of the 
Membrane with the Columella passing to the Fene- 
stra Ovalis ; b. The Fenestra Rotunda, with a bristle 
passed through into the Cochlea ; c. The posterior 
and external Canals crossing each other ; d. The 
Superior Semicircular Canal. 

Fig 3. — An internal view, the reverse of the above, showing — 
a. The inner surface of the Membrane ; b. The Semi- 
circular Canals ; c. The Cochlea laid open with a 
bristle introduced through the Foramen Rotundum. 



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Fig. 3. 




TYMPANUM. 29 



Section V. 



The third Division of the Ear, — The Tympanum, 
which is so named from its partial resemblance in struc- 
ture, and more intimate in function, to a drum, is of 
much less importance in the economy of hearing than 
the foregoing portions ; being placed between the laby- 
rinth and the surrounding medium, simply for the pur- 
pose of producing unison, and increasing strength in 
sounds. In animals which are possessed of an external 
Ear, properly so called, the tympanum constitutes the 
middle Ear. It is situated in the outer part of the petrous 
portion of the temporal bone in higher animals, and oc- 
cupies the os quadratum or tympanic bone of birds. It 
may be correctly defined as a pouch of mucous mem- 
brane, placed in a cavity of the petrous bone, separated 
from the labyrinth by a septum, partly osseous, and 
partly membranous ; the membranous portion occupying 
the fenestra ovalis, and another opening to be mentioned 
presently, termed the fenestra rotunda : it is divided from 
the surrounding medium by the membrana tympani; 
communicates with the respiratory and digestive canals, 
by a peculiar tube, the Eustachian ; and by certain pro- 
longations, extends into the cells of the cranium. The 
Tympanum is traversed by a single bone, the columella, 
or by a chain of three or four bones, the ossicula auditus, 
more or less horizontally extending from the inner sur- 
face of the membrana tympani to the outer surface of the 
membrana fenestras ovalis. When a chain exists, the 
bones form angles with each other, more or less acute, 
and which may be varied by the action of certain mus- 
cles and elastic ligaments attached to the bones them- 
selves. These ossicula convey the vibrations from the 
outer to the inner membrane, and having their angles, 
movements, and rotations varied and alternated, produce 
unison in, and thus influence the power of sounds. 

We have seen that the external membrane of the lob- 
ster, and also of the skate, is to be considered as be- 
longing to the fenestra ovalis, the slight elongation of the 

4 



30 GENERAL OBSERVATIONS. 

vestibule which this membrane bounds, not being at all 
identical with a tympanum, though at first sight it may 
be so imagined ; inasmuch as the membrana tympani of 
reptiles and amphibia, very closely resembles the mem- 
brana fenestrse ovalis of those lower beings. The tym- 
panum is first found in the amphibia, and is further 
perfected in reptiles and birds, in which creatures it is 
very similar, with one or two unimportant exceptions, 
but is particularly neat and compact in the latter (Plates 
V. and VII.). 

The membrana tympani, which in all these, as in the 
higher classes, is set in a groove in the petrous bone, is 
almost circular in the frog, tortoise, &c, the perpendicu- 
lar diameter being slightly the longer : it is nearly a 
double plane ; when otherwise, it is concave without and 
convex within. This membrane is formed by the mu- 
cous lining on its inner surface, and on its outer by the 
integument ; but it is probable that it possesses a distinct 
intervening structure. Sir Everard Home described a 
muscular plane, radiating from the circumference to the 
centre, between the two reflected membranes, as being 
distinctly seen in the elephant and some other animals, 
and he suggests its existence throughout the whole series. 
In the amphibia the external covering of the membrane 
is very thick, and thus affords the protection required by 
aquatic existence, whilst in land reptiles and in birds it 
is much thinner, corresponding to their habits. The 
crocodile, living so frequently in air, is admirably fur- 
nished with an elongation of skin beyond the membrane, 
which, being valvular, forms a meatus externus when 
open, during the terrestrial sojourn of the creature, but 
becomes closed upon the membrane, when it plunges 
into the water, thus the organ is better adapted than in 
the other species of reptiles, for the reception of aerial 
sounds. 

In these various classes the inner surface of the mem- 
brane gives attachment to a slender trumpet like ossicu- 
lum, which is slightly expanded at the outer extremity, 
where fixed to the membrana tympani, whilst it is con- 
siderably enlarged at its inner end, in order that it might 
be accurately fitted to the margin of the fenestra ovalis 



EUSTACHIAN TUBE. 



31 



and its membrane ; this delicate little bone, termed the 
columella from its shape, is no doubt correctly described 
as the rudiment of the stapes of higher animals (Plate V.). 
Two, or as some enumerate three, cartilages are united 
to the columella and the membrana tympani, probably 
influencing the movements of the bone ; these are sup- 
posed to be rudiments of the malleus and incus, and some 
would add also of the orbicular. A muscle proceeding 
from above the tympanic membrane, is inserted into the 
bone ; and it appears that the rudimentary malleus re- 
ceives the attachment of two other muscular fasciculi. 

The Eustachian tube, which runs inwards and forwards 
from the lower and forepart of the cavity, to the pharynx 
or mouth, is very large in all these classes. In the frog, 
it is little more than a prolongation of mucous membrane, 
and opens in front of its well-developed velum palati ; it 
is so large, and so arranged, that when the capacious 
mouth is opened, the orifice becomes distended to a de- 
gree rendering it probable that sound reaches the tym- 
panum through its channel : in the crocodile, the tube 
opens near the occipital condyle, and is thus protected 
by its valvular pharynx ; in birds this canal joins its fel- 
low, and thus they form a common opening in the me- 
dian line of the upper part of the pharynx, w T here it is 
deprived of cartilage. In the cetacea the tube is very 
large, and opens into the upper part of the blowing appa- 
ratus, where it is furnished with valves worked by mus- 
cles, by which contrivance the animal can prevent water 
from entering the tympanum ; whilst air is freely ad- 
mitted. By this arrangement the passage seems to be- 
come an accessory external Ear, receiving and conveying 
those sounds most important to the animal when floating 
upon the ocean's surface for the purpose of respiration. 
In this tribe a curious separation of the tympanum from 
the labyrinth exists, always in the early periods, and 
often throughout life ; the tympanum being a bone rolled 
up upon itself; thus corresponding somewhat to the divi- 
sion of the petrous portion of the temporal bone in the 
human foetus (Plate VIII.). 

In mammalia the four ossicula auditus are completed, 
or three, if the orbicular be considered an epiphysis of the 



32 GENERAL OBSERVATIONS. 

incus ; the malleus is attached to the membrana tympani, 
the incus to the malleus and to the orbicular, as well as 
to the parietes of the cavity : the orbicular intervenes be- 
tween the incus and the stapes; which last extends inwards 
to the fenestra ovalis. These fanciful names were given 



PLATE V. 

Fig. 1.— Transverse vertical section of the Cranium of the Owl. 
A. Cavity of the Cranium seen from behind, a. Tym- 
pana ; b. Their^ommunication through the medium 
of the Cranial Cells ; c. Semicircular canals ; d. 
Meatus externus ; e. Membrana Tympani ; f. Fora- 
men Magnum. 

Fig, 2. — Ear of the Turtle, a. Cartilage corresponding to the 
Membrana Tympani ; b. Tympanum enlarged at 
both extremities ; c. The long Columella ; d. The 
Vestibule with its Membrane ; e. Semicircular 
Canals. 

Copied Views of Stapides and Columellas. From Sir A. Carlisle's 

Plate. 

times times 

Pig. magnified. Fig. magnified. 

3. Hedgehog 4 15. Kangaroo 4 

4. Mole 6 16. Duckbill 4 

5. Musk Ox 2 17. Goose (and its Cartilage) 2 

6. Elephant nat. size. 18. Egyptian Ibis (from a 

7. Tiger 2 Mummy) 3 

8. Dog 3 19. Turtle (Testudo Midas) 

.9. Horse 2 and its Cartilage nat. size. 

10. Pig 3 20. Gangelic Crocodile do. 

11. Marmot with its Pessulus 4 21. Turtle (Testudo Coria- 

12. Seal 2 cea) nat. size. 

13. Porpoise 2 22. Frog (and its Cartilage) 2 

14. Walrus nat. size. 23. Toad 2 

A. General form of the organ of hearing in the fowl. — a. Ante- 

rior Semicircular canal ; b. External, and c. Poste- 
rior, coalescing ; d. The Cochlea ; e. Fenestra Coch- 
leae ; f. Fenestra Vestibuli closed by the base of the 
Columella, g. 

B. Internal view of the same, exhibiting the superior Canal, 

and — a. Cavity of the bony Cochlea. 
0. The ear of the Frog ; showing the Membrane of the Tym- 
panum, the cavity laid open, and traversed by the 
.Columella ; also the Vestibule with its Otoconie. 



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USES OF THE TYMPANUM. 33 

to the bones, partly from their supposed resemblance to 
the hammer, &e., and partly from their conceived func- 
tion, it being imagined by the Antients that they actually 
struck against each other in the production of sound. 
The stapes, which is by far the most important of the 
whole series, is the first which is developed, and becomes 
gradually perfected in the classes of mammalia, as hear- 
ing is more required ; thus, in the walrus it is broad, but 
imperforated ; in the porpoise it is almost solid ; it has 
two columns in the seal, and the opening between thern 
gradually enlarges in the tiger, mole, and marmot to man 
(PL V., 'figs. 3 to 23). 

To the malleus and stapes of mammalia, as to the single 
bone of inferior classes, are attached small muscles, which 
act through their medium to relax or tighten the mem- 
branes. In proportion as acute hearing is requisite, the 
tympanum is extended by communicating with the cells 
of the neighbouring bones ; in man, with the mastoid ; 
in the ferae, with cells at the base of the cranium, consti- 
tuting the bullae ; in birds, with the cells of the cranium 
in general, and which are very large in nocturnal birds, 
as the owl. (PL V., fig. 1). The fenestra rotunda is oval 
in birds, and is not strictly round even in mammalia. 

It is perhaps impossible, in our present state of know- 
ledge, to understand the precise use of the tympanum 
and its appendages. That it is not necessary to hearing, 
is evident from its absence in the vast multitudes of ani- 
mals noticed above ; and further, from the fact of its 
nearly total destruction in mammalia, and particularly in 
man, being unattended with a corresponding diminution 
of the sense, audition being rather impaired than lost, 
and that not to any very great extent when the stapes 
remains attached and the labyrinth healthy. It does, 
however, appear to be necessary, by transmitting the 
slighter vibrations from the membrana tympani to the 
vestibule, to increase or to decrease the power or strength 
of sound ; and hence the undulations of the atmosphere, 
being much more minute and indistinct than those of a 
denser medium, a tympanum is required to increase their 
power in terrestrial inhabitants. It is probable, also, that 
by the action of the muscles varying the state of tension 



34 GENERAL OBSERVATIONS. 

of the membranes of the tympanum and of the fenestra 
ovalis, and by the minute and rapid changes in the angles 
formed by the bones, a concord or unison may be pro- 
duced, adapted to the sensorium which is to receive the 
impression ; if this be true, this third division of the Ear 
becomes the musical portion. With a large external open- 
ing, admitting a constant current of air, evaporation must 
be so great, and the injurious contact of foreign bodies so 
certain, that an intervening portion between the labyrinth 
and outlet becomes necessary for the protection of the 
essential part ; and a tympanum happily exists as a means 
of protection, and at the same time of perfection of audi- 
tion. The Eustachian tube is doubtless serviceable as 
an excretory duct for the escape of any superabundant 
secretion, constituting an outlet corresponding to all other 
mucous sacs and canals. It also admits readily an ingress 
and egress of atmosphere, for the purpose of maintaining 
the membranes in a due state of tension, and of occupy- 
ing the communicating cells ; through it also, in some 
classes, as above stated of the cetacea, the sonorous rays 
may be conveyed to the tympanum, as indeed it is said to 
be in persons deaf from disease of the outer Ear ; of this 
fact, however, there is considerable doubt, and the subject 
must be again referred to. The advantages derived from 
the communication of the tympanum with the cells of the 
cranial bones, appears simply to be an increase of extent, 
by which means an increased vibratory medium is ob- 
tained, producing a greater effect. 



Section VI. 

The fourth and last Division of the Ear is decidedly the 
least important, being merely an addendum for the recep- 
tion and condensation of a greater number of sonorous 
rays than could otherwise impinge upon the membrane. 
A true external Ear exists only in the mammalia and the 
very highest reptiles, being unnecessary in a denser sur- 
rounding medium than the atmosphere. It is very cor- 
rectly subdivided into the meatus auditorius ezternus, 
and the auricula or pinna. Both divisions are essen- 



EXTERNAL EAR. 35 

tially formed of very elastic thin fibro-cartilage, variously 
folded, and covered by a delicate and vascular reflection 
of the integument, which in some instances is particu- 
larly sensitive. The meatus is generally partly formed, 
in the adult Ear, of a projection of bone from the pars 
petrosa. The auricle is furnished with muscles ; intrin- 
sic, attached to the cartilage only to occasion the move- 
ments of its different processes ; extrinsic, proceeding 
from the neighbouring parts to move the whole auricle 
upon the side of the head. 

It has been seen that the simple Ear of the Crustacea 
reaches the surface by the membrane of the fenestra 
ovalis, which is thus directly in contact with the circum- 
ambient fluid; this may be considered as an external 
Ear, though differing widely from an external appendage. 
In some few fishes, as the skate, a somewhat similar pro- 
longation of the vestibule, as has been observed, opens 
beneath the integument, near the eyes, thus becoming 
almost external, and without doubt influenced directly 
by the surrounding fluid. Reptiles have a rudiment of 
an outer Ear, superadded to the tympanum, consisting of 
a thickened process of integument, defending the mem- 
brane only, and having no influence in the collection of 
sounds ; though in the crocodile this integument is elon- 
gated into a rudimentary meatus when the creature is 
on land, and folded, by its valvular arrangement, upon 
the surface of the membrane during its aquatic sojourn. 

Birds, having an internal apparatus a little more per- 
fected than reptiles, and residing constantly in the atmo- 
sphere, are consequently furnished with a rudimentary 
external Ear : but as this, if a projecting organ, would 
interfere with the rapidity of their movements, it consists 
merely of a short membranous tube, varying in diameter 
and length, and placed between the os quadratum and os 
occipitis ; it is rendered irregular by a fold, extending part- 
ly across it from the lower and posterior surface. This 
meatus is furnished with sebaceous follicles ; and, accord- 
ing to De Blainville, its orifice is defended by two small 
cartilages, acted upon by the common cutaneous muscle. 
Around the orifice the feathers are neatly arranged, 
performing to a certain extent the part of an auricle, the 



36 



GENERAL OBSERVATIONS. 



inferior in particular defending the aperture (Plate VI.). 
These feathers conceal the opening under ordinary cir- 
cumstances, but are capable of being separated by the 
cutaneous muscle, at the will of the bird. This adapta- 
tion is admirably seen in the owl, whose nocturnal habits 
require the meatus to be unusually developed, and the 
folds to be so well marked, as in a slight degree to re- 
semble the outer ear of higher animals (Plate VI., fig. 3). 
The ostrich and buston also are furnished with an exter- 
nal development resembling an auricle. 

This appendage becomes particularly, but at the same 
time gradually developed in mammalia ; thus in the ce- 
tacea, the meatus only exists, and is merely a long, nar- 
row, curved tube, extending from the membrane, having 
a very small external aperture (Plate VIII., fig. 4). Its 
structure is in this class peculiar, the bony portion being 
deficient, and the tube formed of cartilaginous pieces over- 
lapping each other; by this arrangement the length of the 
canal is capable of adaptation to the varying quantities 
of blubber which at different times surround this portion 
of the apparatus ; thus, when much adipose matter is ac- 
cumulated, the tube is lengthened, but when the animal 
becomes emaciated, it is shortened by the approximation 
and overlapping of the pieces, and thus is the opening 
always maintained upon the surface of the head. 

Almost all the mammalia are possessed of a pinna, 
larger or smaller, consisting of a considerable development 
of the integument, containing, between its folds, portions 



PLATE VI. 

Fig. 1. — The external ear of the Domestic Fowl, with its 
feathery covering. 

Fig. 2. — The same, the feathery covering being removed. 

Fig. 3. — The external ear of a young white Owl, exposed by 
simply pressing the down aside. — a. Termination 
of the external skin surrounding the Orifice of the 
ear. b. The anterior flap or opercular fold of the 
ear. c. A part of the Tympanic, or quadrate bone, 
d. The Membrana Tympani. e. The Eye. 



Flate 6\ 



Fig /. 




Fig. 2. 




Fz<?3. 




AURICLE. 



37 



of fibrocartilage, by which it acquires support, elasticity, 
and mobility. The cartilaginous portion of the meatus 
is divided into several pieces, which are united together 
and to the osseous portion, by cellular membrane, by the 
perichondrium, and by the reflected integument, thus in- 
creasing its mobility without impairing the unity of sur- 
face. The same separation is evident in the auricle of 
most animals, though in some, as in man, the divisions 
are incomplete. These portions are so disposed, that the 
inferior being moveable, defend more or less the external 
orifice ; and the form as well as the size of the whole au- 
ricle varies considerably from the flat pinna of the simise 
and man to the prominent cornet of the ruminant, — to 
which reference will be particularly made in the descrip- 
tion of the human Ear. 

The size, shape, and direction of the concavity of the 
auricle are adapted to the habits of the animal. In timid 
creatures and those which are pursued, as the hare, rab- 
bit, and ruminants in general, this structure, fully deve- 
loped, is inclined backwards, towards the direction from 
which the sound of their pursuer usually proceeds, whilst 
at the same time, being very moveable, it may be laid so 
flat upon the head and neck, as not to impede the rapid- 
ity of their flight. In pursuing animals, on the contrary, 
as the carnivora, the auricle, which is small, is directed 
forwards, evidently with a view of guiding them to their 
prey (Plate VII., figs. I and 2). Many animals which are 
frequently rushing through thickets or brushwood, &c, 
are furnished with long pendulous pinnae for the protec- 
tion of the meatus. It has been long observed that the 
Ear becomes pendulous in proportion to the domestication 
of the animal, as is evidenced by the comparison of the 
tame and wild beings of the same species, as of the dog, 
pig, sheep, rabbit, &c, &c. ; and the very long and pen- 
dent appendage of the spaniel of King Charles's breed is 
considered its greatest beauty, as marking its long unin- 
terrupted lineage from a favourite and unmixed stock 
(Plate VIL, figs. 3 and 4). This peculiarity is therefore 
esteemed a badge of slavery, the result of their depen- 
dance for support upon their master's bounty, rather than 
upon their own activity. 

5 



3g GENERAL OBSERVATIONS. 

The intrinsic muscles are nearly similar throughout ; 
they are arranged so as to elevate the prominent carti- 
lages, and consequently to deepen the cavities, and to pro- 
tect the meatus. The extrinsic muscles are much larger, 
performing the important office of turning the outer Ear 
towards the direction of the sound; these are anterior, 
posterior, superior, and inferior, in fact they quite surround 
the Ear, no distinct separation existing between them ; 
they may also be divided into deep and superficial, the 
latter being apparently continuations of the general cu- 
taneous muscle, the former proceeding from the neigh- 
bouring bones and fasciae. Of these, anatomists have 
described six anterior, seven posterior, three superior, 
and one inferior, corresponding to the relative capability 
and necessity of movements in the different directions. 
Besides these, at least two muscles are attached to the ex- 
ternal half of the meatus, to vary its diameter. It is found 
that man possesses the fewest external muscles, and the 
ruminant the greatest number. 

The integument of the external Ear has nothing pecu- 
liar where covering the auricle excepting being thinner, 
and perhaps more than usually vascular ; where lining 
the meatus the follicles are large and numerous, and their 
secretion being particularly waxy, they are termed ceru- 
rninous. This modification affords an increased security 
against the entrance of insects, and prevents an undue 
evaporation. 



PLATE VII. 

Head of a Bull-frog {Rana Pipiens) showing the very large 
Membrana Tympani, a. a. 

Fig. 1. — The head of a black Wolf, with the ears directed 
forward, as in all predaceous animals. 

Fig. 2. — The head of a rabbit, exemplifying the direction back- 
wards of the ears of fugacious animals. 

Fig. 3. — The head of a lopped-eared Rabbit, and 

Fig. 4. -— Portrait of a Spaniel, — both showing the effect of 
domestication and breeding in modifying the ear. 



JPlaZe 7. 




Fig.1. 



Fzg. 2. 





FLg.4<. 



Fig. 3. 





ON THE EAR. 39 

The uses of the fourth division of the Ear are evidently 
to protect the tympanum and especially its membrane ; 
to collect a greater number of the sonorous rays, and to 
condense them towards the meatus, — which, by its 
oblique, and in some instances tortuous course, increases 
their power by reflection from its walls, and directs them 
somewhat to a focus upon the membrane. 

It has occurred to the writer, and, without any com- 
munication upon the subject, likewise to a friend, while 
dissecting the ear of the porpoise, — that the external ear 
of the Cetacea does not serve the usual purpose above 
stated; but that the sonorous waves are conducted along 
the Eustachian tube into the cavity of the tympanum 
and the large hollow bone, which is peculiar to these 
animals, and there excites the vibrations of the small 
bones, the tube thus becoming functionally the external 
ear ; — and that the meatus auditorius externus performs 
the office of the Eustachian tube of other classes, by ad- 
mitting air, or perhaps in this instance water rarefied by 
the temperature of the animal, to counterbalance the 
pressure within, and occasionally to assist in producing 
the vibratory movements of the membrana tympani. 
This opinion is deduced from the anatomy of the organ, 
and from the habits of the creature. It will be seen, 
upon reference to the sketch of the Whale's ear, copied 
from that of Sir Everard Home, and to that of the porpoise 
(Plate VIII. ), that the meatus is particularly small, tortu- 
ous, and long ; that the membrana tympani is convex ex- 
ternally, and concave within, exactly opposed to that of 
other mammalia ; that the malleus is not attached to the 
membrane directly, but indirectly to it and the concave 
bone, by a triangular membranous ligament; that the 
other attachments of the bones are as ordinarily found; 
and that the Eustachian tube which communicates with 
the blowing apparatus is especially large. These anato- 
mical arrangements would seem to indicate that the 
ossicula could oscillate to a greater extent than that in- 
duced by the membrane ; that their movements may be 
facilitated by the large volume of air contained in the 
concave-bone; that the membrane may vibrate from 
within ; and that perhaps its most important use was to 



40 GENERAL OBSERVATIONS. 

protect the tympanum. These probabilities are much 
strengthened by the habit of the animal reposing so near 
to the water's surface, that the Eustachian tube has a 
direct communication with the atmosphere at the same 
time that the external meatus is submerged ; a situation 
in which the creature has the greatest necessity for acute 
hearing, and one which it is obliged often to seek for pur- 
poses of respiration. The weight of this opinion is in- 
creased by the somewhat similar suggestions of the late 
Sir Everard Home. 



PLATE VIII. 

Fig. I. — Internal View of the Tympanum and Cochlea of the 
Whalebone Whale, a. Internal Surface of the con- 
cave bone. b. Fatty case in which it is enclosed. 
c. A convexity covered by a thin ligamentous Perios- 
teum, the fibres of which are radiated, and connect 
the Membrana Tympani as well as the Membranous 
fold, f, to the bone. d. Hollow formed by the Mem- 
brana Tympani. e. The external Surface of the 
Membrana Tympani. f. The membrane stretched 
across from the Concave bone to the Malleus, g. 
h. The incus ; i, the Stapes ; k, the Cochlea. 1. The 
Auditory nerve ; m, the bone connecting the petrous 
portion to the skull. 

A. Malleus. 

B. Incus of the Whale. 

C. Stapes. 

Organ of Hearing in the Porpoise. 

Fig. 2. — a. Portion of the bone containing the Vestibule; 
b, acoustic nerve ; c, portio dura ; d, cavity of the Tym- 
panum, e. Malleus ; f. Incus ; g. Stapes, h. Inner 
surface of the Membrana Tympani. i. Muscle and 
ligament connecting the membrane to the Malleus, 
j. Muscle of the Malleus. 

Fig. 3. — Upper portion of the bone removed. 

D. Meatus Auditorius Externus, dissected out. 



PlaZe fr 



Figr.t 




AURICLE. 41 



CHAPTER II. 

ANATOMY OF THE HUMAN EAR. 

In treating this division of our subject it is purposed to 
reverse the order hitherto observed, according to which 
the most important part of the organ was first described, 
and subsequently the least essential ; and to consider, in 
the manner found in the schools to be the most conve- 
nient, the various structures as they appear in the pro- 
cess of dissection. 



Section I. 

The Ear is correctly enough divided into three parts, 
the external, the middle, and the internal Ear. The first, 
including the auricle and external auditory canal. The 
second, the tympanum and its appendages, — and the 
third, the labyrinth, and the aqueducts. From the gene- 
ral history of the Ear which has already been given, it 
would appear to be more philosophical to make a fourth 
division, even in the human organ, by arranging the 
labyrinth under the two heads adopted by comparative 
anatomists. 



Section II. 

The External Ear (Plate IX., fig. 1), takes its deno- 
mination from the circumstance of its situation upon the 
side of the head, thus becoming an external feature; the 
term, however, includes the entire portion placed exter- 
nal to the membrana tympani, part of which is con- 
cealed ; hence, the division into auricula, and meatus 
auditorius externus is very justifiable. 

The Auricle {Auricula) is the fibro-cartilaginous ex- 
pansion covered by integument, by which, as well as by 



42 



ANATOMY OP THE HUMAN EAR. 



muscles and cellular membrane, it is attached between 
the mastoid process, and root of the zygoma of the tem- 
poral bone, partly overlapping the former, and ascending 
upon the posterior part of the temple. It is sub-divided 
into the pinna, and the lobus ; the former being the su- 
perior fibrocartilaginous portion, the latter the inferior 
fleshy appendage. 

The Pinna constitutes by far the chief part of the auri- 
cle ; it is furnished with elevations and processes, and 
corresponding depressions, so arranged as to form a con- 
cavo-convexity ; the concavity being superficial and well 
adapted to receive sound, is termed the concha, and to 
this the rest of the auricle is subservient. The margin 
of the pinna is folded outwards, forming an elevation, and 
from its surrounding the rest of the organ is named helix ; 
it commences above the centre of the concha, which it 
divides into two unequal portions, and then proceed- 
ing forwards and upwards, passes backwards on the 
superior margin, and descending along the posterior edge 
terminates in the lobus. The anti-helix is so called in 
consequence of its situation on the inner border of the 
helix. It commences by two crura behind the anterior 
part of the helix, above its crus, and below its upper 
edge ; the inferior process forms the superior boundary 
to the concha, whilst the two crura, by their union, form 
a considerable prominence, which, constituting the pos- 
terior wall of the concha, descends to the antitragus. 
The groove which is necessarily formed between the 
helix and the anti-helix, has received the names of cavi- 
tas, ox fossa innominata. The oval depression between 
the crura of the anti-helix has been called the scapha, 
fossa navicularis, fossa ovalis, &c. ; indeed, the names 
given to the two depressions have been frequently con- 
fused. The lower part of the concha is defended by two 
interesting processes, the tragus and the antitragus. The 
tragus, fancifully named from the circumstance of its being 
furnished with a few short hairs for the purpose of fur- 
ther protection, constituting a far-fetched resemblance to 
the hide of a goat, is placed in front of the meatus and 
projecting outwards and backwards, conceals under ordi- 
nary circumstances that opening. The antitragus is a 



AURICLE. 



43 



smaller prominence, placed behind the orifice opposite 
to the tragus, projecting outwards and slightly forwards, 
it receives the termination of the anti-helix. These two 
bodies, being united below, form the inferior boundary of 
the concha, and being moveable will have, in quite a 
natural state, considerable influence in protecting the 
meatus. The concha becomes deeper and narrower from 
above downwards, and at its lower and fore part, behind 
the tragus, is placed the orifice of the meatus, somewhat 
contracted by its cartilaginous border. 

In a perfectly natural condition a few pale muscular 
fibres are found attached to these prominences, for the 
purpose of still farther elevating them, in order to deepen 
the cavities, and thus to render them better adapted to 
conduct the sound to the meatus ; in the Ear of the civil- 
ized being, in consequence of the mode of dress, and 
acute listening to distant sounds not being so frequently 
necessary, these muscles are so rarely used, that a little 
thickened fibro-cellular membrane is all that can gener- 
ally be found. They are indeed hardly more developed 
in uncivilized tribes, being under all circumstances merely 
rudimentary. 

1st. The Tragicus proceeds from the inferior edge of 
the tragus, runs along its outer surface to its upper margin, 
and sometimes reaches the edge of the helix. When de- 
veloped this muscle will draw the tragus forwards, and 
thus uncover the meatus. 

2d. The Antitragicus proceeds from the outer surface 
of the upper margin of the antitragus, to the inferior edge 
of the anti-helix. It will approximate these two portions 
of cartilage, and draw the antitragus a little outwards and 
backwards, assisting in opening the meatus. 

3d. Helicus Major lies upon the external surface of the 
anterior portion of the helix, extending from its inferior 
extremity to its superior curve backwards, where sepa- 
rated from the head. Use, to draw the concha a little 
backwards and downwards, and to deepen the cavitas 
innominata. 

4th. Helicus Minor, the smallest of the muscles, is pos- 
terior to the major ; lying upon the horizontal commence- 



44 ANATOMY OF THE HUMAN EAR. 

merit of the helix, it passes forwards to its rim. The 
action is to draw the helix slightly downwards. 

5th. Posterior vel Transversalis Auris is placed on the 
posterior convex surface of the concha ; it is the largest 
muscle, and runs across from the anti-helix to the fossa 
scaphoides. It deepens and enlarges the concha. Mr. 
Tod has described two other muscles, obliquus auris, 
and trago-helicus. Quadrupeds, whose tragus and anti- 
tragus are well developed, are furnished with a powerful 
tragico-antitragicus, which approximates these two bodies 
and closes the meatus. 

The Lobus is the fibro-cellular and somewhat fatty in- 
ferior appendage to the pinna ; it hangs below the helix 
and antitragus, of which it resembles a continuation, and 
varying considerably in size in different individuals ; it 
is frequently lengthened downwards to a degree of de- 
formity by the weight of supposed ornaments. It does 
not appear to be of further use than to complete the 
auricle. 

The fibro-cartilage of the pinna is highly elastic, and 
is formed of several pieces, which, having slight fissures 
between them, are firmly united together by condensed 
cellular membrane, constituting the intrinsic ligaments ; 
the cartilage is particularly prominent where the inferior 
extremities of the helix and anti-helix unite, and here 
the lobus is appended. The skin of the auricle is thin 
and very vascular, receiving its vesselsfrom the posterior 
aural artery, and by means of the anterior aural, from 
the temporal; its nerves are also tolerably abundant, being 
derived from the portio dura and from the superior cervi- 
cal plexus by means of the auricularis magnus. The 
lobus is, fortunately for the custom of ear-boring, less sen- 
sitive than the pinna. The skin becomes gradually thin- 
ner from the margins to the meatus, where it approaches 
the character of mucous membrane. The high organ i- 
zation of the skin well capacitates it for resisting the in- 
fluences of variations of climate to which it is so much 
exposed. The auricle is fixed to the neighbouring parts 
by short strong cellular membrane, which have been 
termed the extrinsic ligaments, as well as by the skin and 
muscles. 



AURICLE. 



45 



The extrinsic muscles consist of three sets of pale fibres, 
— 1st. Attollens Aurem is the largest muscle, yet very 
thin, of triangular form, with a rounded base ; it arises 
from the centre of the lower edge of the tendon of the oc- 
cipito-frontalis, and partly from the temporal fascia ; the 
fibres converging terminate in a short tendon, and are 
thus inserted into the upper and posterior part of the 
pinna, behind the scapha. This muscle will raise the 
auricle, particularly during the action of the occipito- 
frontalis. 

2d. The Retrahentes Aurem are always two, and some- 
times there are three slips placed above each other, often 
well marked ; they arise from the outer and anterior sur- 
face of the mastoid process, sometimes connected with the 
long muscles there attached ; they pass directly forwards 
and are inserted into the posterior surface of the concha, 
near to the auditory opening, by short tendons. Use, to 
draw the auricle backwards, and to dilate the concha. 

3d. The Anterior Auris is rarely to be seen in the 
European, its situation being merely indicated by a band 
of strong cellular membrane ; when present, it arises from 
the root of the zygoma, and proceeds backwards and 
slightly downwards, to be attached by a short tendon, 
to the fore and lower part of the commencement of the 
helix. It will carry the auricle forwards and a little up- 
wards. 

The motions of the external Ear are nearly lost to the 
civilized being, from the same causes that have interfered 
with the development of the intrinsic muscles, so that the 
movements that are produced by some persons, can gene- 
rally be accomplished only by contracting at the same 
time the occipito-fron talis ; some few individuals have, 
however, possessed this power, and among others it has 
been so recorded of Albinus : uncivilized tribes enjoy 
this capability to a considerable extent. The exact shape 
and form of the auricle vary in individuals almost as much 
as those of the more prominent features ; and it is inte- 
resting to notice that its variations extend to whole na- 
tions, and that in proportion to the advance of civilization, 
it has been observed to be smaller, more compact, and 

6 



45 ANATOMY OF THE HUMAN EAR. 

oval* assuming the appearance to which the idea of beauty 
is attached ; whereas, in the savage races, it is large, pro- 
minent, and somewhat pendulous, possessing a degree of 
mobility : thus corresponding to the general increased 
development of the organs of external sense, as con- 
trasted with the diminished extent of mental capacity. 

Some writers on acoustics have declared the shape of 
the auricle to be well adapted to receive and concentrate 
the sound, and to direct it to the meatus. It is said, that 
from this circumstance, " the first Dionysiusof Syracuse 
had constructed a subterraneous cave in a rock, in the 
form of the human Ear, which measured eighty feet in 
height and two hundred and fifty in length ; the sounds 
of this cave were necessarily directed to a common tym- 
panum, which had a communication with an adjoining 
room, where Dionysius spent the greatest part of his 
time, to hear whatever was said by those whom his sus- 
picions and cruelty had confined in the apartments 
above." 

The Meatus Auditorius Ezternus, (Plate IX., fig. 1,) 
the narrowed part of the acoustic cornet, is a tube, 
partly osseous, partly cartilaginous, extending inwards 
from the lower and fore part of the concha to the mem- 
brana tympa?ii ; it may be defined as a reflection inwards 
of the flbro-cartilage. It is about an inch and a quarter 
in length, rather more than less; about a quarter of an 
inch in the transverse diameter, and a little more in the 
perpendicular direction, its section being oval. Its course 
is slightly curved, being at first forwards and upwards, 
then downwards and a little backwards, so that its con- 
cavity looks obliquely downwards and forwards ; the 
inferior wall is longer than the superior, accurately cor- 
responding to the oblique position of the membrana tym- 
pani ; the dimensions of this tube vary, it being a little 
contracted at the orifice, still more so in the centre, which 
is the narrowest part, and again at the membrane. The 
cartilaginous portion forms rather more than half the 
meatus, but does not constitute a complete tube, being 
separated into several portions, which consequently pos- 
sess some degree of motion upon each other ; the carti- 
lage is particularly deficient at the upper and outer part, 



EXTERNAL MEATUS. 47 

where the tube is completed by dense fibrous tissue; it 
is ultimately united to the irregular bony edge of the 
osseous portion by dense cellular membrane, in addition 
to the dernal lining. Some anatomists have considered 
that these fibrous connexions are partly muscular, which 
opinion appears to be unfounded. The bony part of the 
auditory canal consists of the processus auditivus of the 
temporal bone, which is completely developed in the 
adult, but is merely an osseous ring in the foetus, at which 
period the entire length of the meatus is fibro-cartila- 
ginous and membranous, corresponding to the structure 
in the lower mammalia. This bony portion is gradually 
increased to the adult age, when it constitutes rather less 
than half the meatus, and projects between the mastoid 
and vaginal processes, the latter assisting in forming its 
anterior wall, and in giving the obliquity alluded to above. 
The perichondrium and periosteum are continuous, and 
passing over the fibrous connexions of the portions of car- 
tilage and the bones, perfect the tube. The meatus is 
lined by a reflection of the skin, here so modified as to 
assume partly the characters of a mucous membrane, and 
which is also accurately adapted to the external surface 
of the membrana tympani, resembling the arrangement 
we have noticed in reptiles. The lining membrane is 
peculiarized by its great delicacy, which becomes remark- 
able in the osseous portion ; by the soft and fine downy 
capilluli, which exist throughout the whole tube, but do 
not extend upon the tympanal membrane, and by which 
it retains its cutaneous character ; and, lastly, by the 
great number and large size of its follicles, which are oc- 
cupying the subjacent tissue. These glands, which are 
chiefly confined to the outer half of the meatus, send 
their ducts obliquely through the membrane, to open 
upon its surface; their secretion differs from common 
mucus, being thick, yellowish, viscid and inflammable, 
bitter, and containing an oily fat, albumen, colouring 
matter, and a peculiar animal matter, thus having some- 
thing the appearance of wax ; it has been named cerumen 
aurium, the follicles themselves being consequently called 
glandular ceruminosce. The cerumen, by its inspissation, 



43 ANATOMY OF THE HUMAN EAR. 

will prevent too rapid an evaporation, ensuring a moist- 
ened condition of the surface, thus preventing too great 
a degree of reflection of the sonorous rajs ; and it will 
especially interfere with the encroachments of insects, 
being probably poisonous to them, as well as preventing 
their movements by its tenacious principle. The lining 
membrane is also furnished, at the outlet of the meatus, 
with numerous short hairs, which in advanced age are 
long and strong enough to project considerably beyond 
the tragus. The hairs protect the tube against the en- 
trance of small insects, at the same time that, by entan- 
gling among them a layer of warmed air, they prevent the 
too sudden transition from heat to cold, in some manner 
performing the office of the respirator. 

The meatus auditorius externus receives the sound, 
concentrated by the auricle, and conveys it to the rnem- 
brana tympani ; but that is not all ; it is a well-seasoned 
wind-instrument, and reflects the rays from its parietes, 
by which their power is increased and in virtue of its 
peculiar obliquity and shape, without a doubt, it forms 
them into a focus, which falls upon the membrane with 
much increased influence. It has been seen that many 
mammalia have probably two muscles to enlarge its ca- 
pacity, and it is suggested by Richerand, that the partially 
deaf man, by opening his mouth and advancing the con- 
dyle of the lower jaw, may also increase the diameter of 
the tube, for the purpose of transmitting more freely the 
sound. Through the arrangement of the external Ear, 
the middle is securely placed deeply in the cranial bones, 
and maintained in the moistened condition so necessary 
to its functions. 



Section III. 

The middle division of the Ear, consists of the tym- 
panum and its appendages, namely, the membrana tympani, 
the four ossicula auditus, with their ligaments and mus- 
cles, the Eustachian tube, and the mastoid cells. (Plate IX., 
figs. 1, 2, 3, 4, 5.) 



TZale S. 



Fi#3 Fi#.4< Fig. 5. Fig. 6 




Fi<? /3. 



EXPLANATION OF PLATE IX. 49 



PLATE IX. 

The different Figures are faithful representations of recent 
Dissections of the Human Ear. 

Fig. 1. — Exhibits the External Ear, Tympanal Membrane, 
and Eustachian Tube on the left side, the Middle 
and Internal Ear being necessarily out of view. 
A portion of the Squamous Plate; — the Mastoid 
Process ; — and the Styloid Process of the Temporal 
Bone ; — the Carotid Artery ; — and Internal Ptery- 
goid Muscle are depicted. On the Auricle are repre- 
sented, the Helix, Antihelix, Cavitas Innominata, 
Scapha, Concha, Tragus, Antitragus, Lobus. In 
the External Auditory Meatus, the Cartilaginous 
and Osseous Portions, with a considerable part of 
the Outer Surface of the Membrane of the Tym- 
panum. The Eustachian Tube, which is laid open, 
has its Tympanic Osseous Portion narrow, and its 
Pharyngeal Cartilaginous Portion much expanded. 
Fig. 2. — External Surface of the left Membrana Tympani, with 
its Blood-vessels ; from a child about four years old. 
Fig. 3. — The Malleus. 4. Incus. 5. Orbicular. 6. Stapes. 
Fig. 7. — The Ossicula Auditus in connection with each other. 
Fig. 8. — A lateral view of the Internal Surface of the left Mem- 
brane of the Tympanum with the Ossicula in situ. 
Fig. 9. — Inner Wall of the Tympanum, with the Fenestra 
Ovalis, Promontory, which conceals the Fenestra 
Rotunda, and the communication with the Mastoid 
Cells : above the Tympanum are Sections of the 
Semicircular Canals. 
Fig. 10. — The Right Labyrinth dissected out of the Petrous 
Portion, and unopened, exhibiting the Fenestra 
Ovalis, and the Fenestra Rotunda. — The Promon- 
tory . — The Superior, and Posterior, and External 
Semicircular Canals. — The Cochlea. 
Fig. 11. — The same laid open, showing the two Membranous 
Sacs in the Vestibule, the Membranous Canals, 
and Membrane of the Cochlea with the Lamina Spi- 
ralis. 
Fig. 12. — A lateral view of the Cochlea, showing the Spiral 
Canal divided into the two Scalse by the Spiral 
Lamina. 
Fig. 13. — Another view of the left Cochlea, showing the com- 
munication of the Scala Vestibuli with the Vesti- 
bule, and the termination of the Scala Tympani at 
the Fenestra Rotunda. 



50 ANATOMY OF THE HUMAN EAR. 

The Tympanum is a cavity situated in the outer and 
rather posterior part of the petrous portion of the tempo- 
ral bone ; irregular in shape, with the antero-posterior 
diameter rather the longest, and about half an inch in 
extent, while the transverse, crossed by the ossicula, is 
the shortest. This cavity is bounded externally by the 
membrana tympani, and internally separated from the 
labyrinth by an imperfect osseous plate, which is perfo- 
rated by the fenestra ovalis and fenestra rotunda ; it com- 
municates at its lower and fore part, with the pharynx by 
means of the Eustachian tube, and at the upper and back 
part with the mastoid cells. The whole is accurately 
lined by mucous membrane, continuous with that of the 
digestive and pulmonary apparatus, and which also ex- 
tends into the cells. 

The Membrana Tympani (Plate IX., figs. ] , 2, 3) merits 
the especial attention of the Surgeon as it is constantly 
interested in diseases of the Ear. It is nicely fitted into 
a groove in the outer part of the pars petrosa, which with 
it forms the boundary between the auditory canal, and 
the cavity of the tympanum ; the membrane is ovoid, 
the broader extremity being above, and the greater diame- 
ter, which is rather less than half an inch in extent, being 
perpendicular ; it is inclined with considerable obliquity 
from above downwards and inwards, the lower edge beinof 
thus internal to the upper ; the outer surface, which is 
directed a little forwards as well as downwards and out- 
wards, forms with the inferior surface of the auditory 
canal, an angle of about 45°. This external surface is 
concave, having a conical depression usually situated a 
little below the centre, although the author has occasion- 
ally found it above, but never exactly in the middle. The 
inner surface is the exact reverse of the external, being 
convex with a corresponding conical eminence, to give 
attachment to a process of the malleus, and is inclined 
inwards, upwards, and a little backwards. This import- 
ant membrane presents a bright silvery appearance more 
or less distinctly fibrous, and particularly upon the inner 
surface, the fibres converging from the circumference to 
the central depression. Vest and Wittman of Vienna 
have repeated the almost forgotten opinion of Rivinus 



MEMBRANA TYMPANI. 



51 



that the membrane is normally perforated, which assertion 
is certainly not correct, for in a healthy condition it con- 
stitutes a complete septum. Various opinions have been 
entertained of its structure; all authorities, however, 
agree, that it is covered externally by a continuation of 
the lining membrane of the auditory canal, though most 
probably it is only furnished with a reflection of the epi- 
dermoid layer, and that internally it is lined by the mu- 
cous membrane of the tympanum. The positive exist- 
tence of a proper membrane between the two reflections 
is not yet determined ; some anatomists even now denying 
the presence of such a structure, whereas others, adopt- 
ing the opinion of Sir Everard Home, which however 
was founded rather upon the dissection of the Ear of the 
elephant, than of that of man, declare it not only to exist, 
but to be in its nature a very active muscle capable of 
great variations of tension and relaxation. 

The most careful examination does not afford evidence 
of such a structure in the human subject, nor have mus- 
cular fibres been seen by some of the most expert anato- 
mists, either in the cetacea, or in the horse ; and as Sir 
Everard Home has in other instances mistaken a fibrous 
structure reddened with blood-vessels for muscle, and as 
physiology leads us to believe that no advantage can be 
gained by such an arrangement in the membrana tym- 
pani, the conclusion may fairly be drawn, that this ex- 
cellent comparative anatomist was in this instance 
deceived. Most Dissectors allow that an independent 
fibrous membrane does exist, and that it is not merely a 
thickening of the mucous surfaces ; the outer reflection 
may be easily separated from it, whilst the inner is very 
thin and firmlv attached. 

The membrana tympani is very well supplied with 
blood ; the stijlo-mastoid branch of the auricular artery, 
and the ramus tympanicus of the internal maxillary form 
a coronary vessel around the osseous margin, from which 
twigs run to the centre, thus presenting an arrangement 
which has considerable resemblance to the blood-vessels of 
the iris. It receives also minute filaments of the nerves, 
from the tympanic plexus, probably chiefly supplied from 
the chorda tympani. 



52 



ANATOMY OF THE HUMAN EAR. 



The uses of the membrani tympani, are to protect the 
cavity and consequently the labyrinth; to vibrate in 
obedience to the impression produced by the sonorous 
waves striking upon its external surface, and to transmit 
such vibrations to the malleus. 

The inner wall of the cavity of the tympanum (Plate 
IX. , figure 5), is rendered irregular by the promontory, 
the fenestra ovalis and the fenestra rotunda. The pro- 
montory is a projection of bone, forming nearly a third of 
the whole surface, situated a little below the centre; it is 
not solid as its name would imply, but is a mere shell, 
constituting internally the parietes of the enlarged com- 
mencement of the scala tympani. It is interposed between 
the two fenestra, and projecting backwards, overlaps and 
defends the fenestra rotunda ; upon its surface grooves 
are observed, which contain the nervous filaments, con- 
stituting the tympanic plexus. 

The fenestra ovalis is placed in front and above the 
promontory, and below a projection formed by the aque- 
duct of Fallopius ; its long diameter is almost transverse, 
but has a slight obliquity downwards and backwards; 
the inferior margin is a little elevated, and thus the oval 
is not perfect. In the dried bone the oval opening leads 
into the vestibule, but in the recent subject is closed by 
a thin fibrous membrane, upon which the base of the 
stapes is accurately fitted, the result of which must be 
that the motions of that bone are communicated to the 
membrane, and thence to the fluid in the vestibule. 

The Fenestra Rotunda, situated behind and below the 
promontory, is directed backwards in such a manner 
as to be nearly concealed : it is rather triangular than 
round, partaking of both shapes, and leads into the scala 
tympani of the cochlea ; in the natural condition this 
opening is also furnished with a membrane, described 
by Meckel as merely the lining of the tympanum, whilst 
Ribes and others more correctly regard it as correspond- 
ing in character to the membrana tympani, but of less 
strength. This structure, which is sometimes called 
membrana tympani secondaria, is set within the aperture 
formed by the bone, and appears more intimately con- 
nected with the cochlea than with the tympanum, though 



EUSTACHIAN TUBE. 53 

covered by the mucous membrane of the latter. It will 
most undoubtedly oscillate, but whether in consequence 
of the influence of the air in the tympanum, or of the 
fluid in the cochlea, will be discussed hereafter. 

The posterior wall of the tympanum furnishes the 
eminentia pyramidalis, which is an irregular little cone 
of bone, perforated for the passage of the stapedius, and 
placed on a level with the inferior edge of the oval 
opening; occasionally a process is continued from its 
apex, forwards and inwards, to the superior edge of the 
promontory, and its canal hasevenbeen traced downwards 
and backwards by M. Huguier, to communicate with 
the Follopian aqueduct. The pyramid appears to be 
only useful to give direction to the action of the muscle. 

Around the superior and posterior margins of the cavity 
a slight elevation forms the wall of the aquseductus Fal- 
lopii, and marks its course ; a small opening, the aper- 
tura chordce, leads from it, behind and below the pyramid, 
giving passage to the chorda tympani. 

The mastoid cells (PL IX., fig. 5) communicate with 
the tympanum at the upper and back part, through the 
medium of one large opening, or several small ones ; the 
cells are a great expansion of the general diploe of the 
skull ; and as the mastoid process varies in size, and its 
tables in the degree of their separation, the cells may be 
larger or smaller, more or less numerous. These exca- 
vations, as has been already stated, are lined by a con- 
tinuation of the mucous membrane of the tympanum ; 
and they may thus be considered as an enlargement of 
that cavity. It is imagined that the air, undulating in 
the cells, and the sound being as it were thus allowed 
to reverberate, its effect will be increased. Moreover, the 
cellular arrangement will certainly be effective in ren- 
dering the bone lighter, and at the same time increasing 
the surface for attachment of the mastoid muscles. 

The Eustachian tube (PI. IX., fig. 1) commences by a 
small aperture at the lower and fore part of the tym- 
panum, whence it proceeds downwards, inwards, and 
forwards, and opens into the upper and lateral part of the 
pharynx, about a quarter of an inch behind the posterior 
opening of the nostril, and at the same distance above 

7 



54 ANATOMY OF THE HUMAN EAR. 

its floor ; its course is thus well adapted to allow the 
escape of mucus from the tympanal cavity. This tube 
is upwards of an inch and a quarter long, elliptical in 
shape, and slightly contracted from the tympanum to the 
cartilaginous portion, where it gradually enlarges to the 
pharynx, in which cavity it somewhat suddenly expands, 
having much the appearance of a straight trumpet with 
the mouth-piece removed. Its tympanic portion, which 
is osseous, and named the Iter a Palato ad aarem, is 
made up of the irregular extremity of the pars petrosa, 
and of the ala and the root of the pterygoid process of 
the sphenoid bone ; the pharyngeal and longest portion 
is fibrous and fibro-cartilaginous, and, in correspondence 
with the bony portion, is more extensive on the inferior 
than on the superior surface; the fibro-cartilage forms 
the superior and internal walls, and the fibrous tissue 
the lower and external surfaces. The tube is lined by 
mucous membrane, which is continuous at one extremity 
with. that of the tympanum, and at the other, where it 
assumes the nbro-mucous character, with the lining of 
the throat ; it is abundantly supplied with mucous 
follicles. 

Along the superior edge of the osseous portion of the 
Eustachian tube is a canal, separated from the tube partly 
by bone and partly by a fibrous membrane, transmitting 
the Tensor Tympani; the extremity of this canal forms 
a pulley, around which the tendon of the muscle plays, 
and is thus directed outwards to the Malleus. 

The Eustachian tube, in the human subject at least, 
appears to be chiefly destined to permit a free ingress 
and egress of air to and from the tympanum ; how far 
it is useful to allow recession, and thus to promote the 
undulations of the air, must be alluded to hereafter. It 
also affords a ready exit for the superabundant secretions 
of the mucous membrane. 

The Ossicula Auditus (PL IX., figs. 3 and 4) are four 
in number in the young subject, and three at the adult 
period. They are named, as in the other mammalia, 
malleus, incus, orbiculare, and stapes, and form an irregu- 
lar chain, stretching across the upper part of the cavity 
from the membrana tympani to the membrana fenestras 



OSSICULA AUDITUS. 



55 



ovalis, th us maintaining the communication between the 
external and internal Ears. The Malleus, not badly 
termed as it somewhat resembles a mallet, is furnished 
with a caput, cervix, processus gracilis, processus brevis, 
and manubrium. The head, which forms the superior 
part, projects above the level of the membrana tympani 
into a cavity termed the tympanic sinus ; it is convex, 
and smooth upon its upper and outer surface, whilst upon 
its inner and rather posterior part is a concave articular 
surface, divided into two by a transverse ridge ; these 
depressions are covered by cartilage, and are united to 
corresponding articulations on the incus. The neck, by 
which the processes are attached to the head, is short 
and contracted, and slightly marked by the attachment 
of muscles and ligaments. The long or thin process is 
nearly as long as the rest of the bone ; it can rarely be 
separated from the skull in a perfect state in consequence 
of its delicacy ; it proceeds from the neck in a curved 
direction forwards and a little downwards, and a fine point 
becomes attached to the inner margin of the tympanic ring, 
close to the Fissura Glasseri. The short process is thick 
and strong, and projects directly outwards, forming a 
right angle with the manubrium, leaving between itself 
and the neck a deep depression ; it is united to the upper 
part of the membrane. The handle, which forms the 
bulk of the bone, descends from the cervix and processus 
brevis, being inclined a little backwards, though occa- 
sionally the Author has seen it forwards, but particularly 
inwards, so as to correspond to the obliquity of the mem- 
brane ; it tapers to an inferior point, which is slightly 
enlarged and turned outwards to be articulated to the 
elevation of the membrana tympani, between the layers 
of which the manubrium is fixed. 

The Incus, though something like an anvil, more nearly 
resembles a molar tooth ; it has a corpus and two crura. 
The body is nearly square and flat, having superiorly 
a concavity, which is divided into two slight eleva- 
tions by a deep fissure : these are covered by cartilage, 
and are directed upwards and forwards to be articulated 
to the head of the malleus ; a most interesting double 
pulley-joint is thus formed. The short crus is much the 



56 ANATOMY OF THE HUMAN EAR. 

thicker, flattish on its anterior and posterior surfaces, be- 
coming gradually smaller to an apex, it projects nearly 
directly backwards to be united to the edge of the mas- 
toid cells by a well marked ligament. The long crus is 
much narrower, as well as longer, and becomes smaller 
to its point; it hangs downwards, a little forwards, and 
inwards, thus diverging from the manubrium of the 
malleus ; the extremity is enlarged into a small button- 
like process, and turned inwards to be articulated to the 
orbicular. s 

Os Orbiculare or lenticulare, is a mere speck of bone, 
and is always a process of the long crus of the incus, in 
the adult Ear, and frequently in childhood ; when it ex- 
ists as a distinct bone, a minute concavity may be recog- 
nised upon its outer surface by which it is united to the 
long crus of the incus, and a better marked convexity 
upon its inner surface to be received into a depression 
upon the head of the stapes. 

The Stapes very much resembles in shape the stirrup- 
iron, possessing a head, neck, two crura, and a base. The 
head is the external, very slight expansion, presenting 
a depression, by which it is articulated to the orbicular. 
The neck is the small portion between the head and 
crura, sometimes contracted, but frequently of the same 
size as the head, and is therefore often not described ; it 
is always marked by the attachment of ligaments and a 
muscle. The crura pass horizontally inwards, diverging 
from each other, and become united to the base; the pos- 
terior crus is more curved, and consequently longer than 
the anterior, thus the bone of one Ear may be distinguished 
from the other. The base exactly corresponds in shape 
to the fenestra ovalis, but is a very little smaller, by which 
arrangement its motions will more perfectly influence 
the membrane ; it is nearly a horizontal oval, being convex 
on its upper margin, and slightly concave on its lower, 
flat and smooth internally where lying in contact with 
the membrana fenestras ovalis. The crura and base are 
grooved upon their opposed faces, to such an extent that 
their walls are transparent ; this groove receives the tri- 
angular ligament to be further alluded to. 

Are these ossicula articulated through the intervention 



MUSCLES OF THE OSSICULA. 57 

of ligaments proper? H. Cloquetsays they are unfurnished 
with ligaments, and are held together merely by the com- 
mon mucous membrane of the tympanum, which he seems 
to believe also constitutes the only periosteum they possess. 
The anatomists of this country, on the contrary, have 
usually described ligaments ; and there can exist but little 
doubt that some of the folds of the membrane, are so 
strengthened as to merit this distinction ; of these par- 
ticularly may be mentioned the triangular ligament, occu- 
pying the space between the crura and base of the Stapes, 
and the ligament of the short crus of the Incus passing 
to the edge of the mastoid cells. So delicate and thin 
are the other ligamentous attachments, that a doubt may 
be justified as to the existence of more than mucous mem- 
brane; there are, however, usually enumerated, 1st. A 
ligament fixing the manubrium and short process of the 
malleus to the membrana tympani ; it is very certain 
that this process of bone is placed between the mucous 
and proper membranes, and its union appears also to be 
strengthened by cellular tissue. 2d. A fine ligament tying 
the long process of the malleus to the edge of the bony ring 
of the tympanum. 3d. A synovial capsule reflected 
from the head of the malleus to the body of the incus ; 
it is more than probable that this exists, as the outline 
of both bones is obscured until they have been cleaned ; 
and as their surfaces are tipped with cartilage, consider- 
able mobility is allowed between them ; thus the articu- 
lation bears every analogy to a perfect joint. 4th. A syno- 
vial capsule between the long crus of the incus and orbi- 
cular, this mode of union, for reasons already stated, can 
only exist in the young subject, and most probably even 
then it is absent. 5th. A capsule articulating the orbi- 
cular to the head of the stapes, appears to be present. 6th, 
and lastly, a ligamento-mucous junction unites the base 
of the stapes to the membrane and margin of the fenestra 
ovalis, similar to that between the malleus and membrane 
of the tympanum. 

These minute bones are furnished with four muscles, 
through the actions of which the membranes are affected. 
So imperfectly developed are some of these muscles, that 
many anatomists doubt the existence of more than one, 



58 ANATOMY OF THE HUMAN EAR. 

considering the others as mere ligaments, and Cruveilhier 
says, that the internus mallei can alone be clearly de- 
monstrated, though he will not deny the presence of the 
others. Whereas Mr. Tod has described many additional 
ones, three being supposed by him to be attached to the 
incus ; it is evident that in this instance folds of mucous 
membrane have been mistaken for muscular fibres. 

The Tensor Tympani, or Internus Mallei, arises from 
the superior surface of the cartilaginous and bony portion 
of the Eustachian tube, and from the neighbouring edge 
of the petrous bone ; it runs backwards and outwards 
along the upper surface of the tube, through the osseo- 
fibrous canal before mentioned, into the cavity of the 
tympanum ; its well formed round tendon winds directly 
outwards round the margin of the canal as through a 
pulley, and becomes inserted into the inner surface of 
the commencement of the manubrium of the malleus, 
just below the long process. This muscle will evidently 
draw the bone inwards, and so tighten the membrane, 
increasing its internal convexity and its external con- 
cavity. 

The Laxator Tympani, or Anterior Mallei, proceeds 
from the spinous process of the sphenoid bone, runs in- 
wards and backwards through the fissura glasseri of the 
glenoid cavity, sends off a long and slender tendon to be 
inserted into the root of the long process of the malleus. 
This muscle will draw the malleus outwards and a little 
forwards, and thus relax the membrane, antagonizing the 
Tensor. 

Levator Tympani, or Laxator Minor, is not always to be 
found, and when present, is very small; arising from the 
upper surface of the processus auditivus, it descends be- 
tween the mucous and proper membrane of the tym- 
panum, to be inserted into the processus brevis of the 
malleus. It will raise the bone and carry it outwards, 
consequently relaxing the membrane. 

The Stapedius arises from one of the mastoid cells and 
bottom of the eminentia pyramidalis ; it passes through 
the canal of the pyramid, and immediately becoming 
tendinous, advances to its insertion in the posterior edge 
of the neck of the stapes. This muscle will carry the 



MUSCLES OF THE OSSICULA. 



59 



stapes backwards and roll the posterior edge of its base 
inwards against the membrana fenestra ovalis, thus in- 
creasing its tension ; it is generally supposed, however, 
to have more influence upon the membrana tympani by 
drawing the chain of bones inwards, and so assisting the 
Tensor tympani. 

The mode of articulation of the bones is admirably 
adapted to increase the influence of the vibrating mem- 
brana tympani : few instances, indeed, of mechanical ad- 
vantage more deserve the admiration of the physiologist. 
The malleus, connected by the whole length of its manu- 
brium, is incapable of separation from the membrane, 
and must therefore receive its minutest motion ; but that 
motion is increased by the bone resting upon the mem- 
brane, chiefly by means of the projections at the two 
extremities, the processus brevis and the curved enlarge- 
ment of the point of the manubrium, by which arrange- 
ment a certain degree of rotation is allowed : this rotatory 
motion is modified, and the bone more firmly secured, 
probably even the vibration of the membrane itself to a 
certain extent limited, by the mode of attachment of the 
long process. The short lever which is formed between 
the manubrium and head of the malleus, will somewhat 
increase the motion. This increased motion is trans- 
mitted to the incus, which is articulated to the malleus 
with such an obliquity, that the centre of motion is 
through the middle of its body and short crus ; the latter 
may be considered as an extension of the former, to secure 
the whole bone more firmly in its position, and at the 
same time, so far from impeding the movements, they are 
most likely increased by this arrangement ; at all events 
th oscillations will hereby be steadied and more readily 
stopped. The long crus hanging and moving freely in 
the cavity will, in proportion to the length of its lever, 
still further increase the motion communicated to it from 
the body : its curved termination forms a most convenient 
attachment for the horizontal bones, which thus form 
almost a right angle with it. The orbicular and stapes 
by the lever, which they thus form, again augment the 
motions received, and convey them to the membrana 
fenestra ovalis. Thus, then,, the vibrations of the com- 



50 ANATOMY OF THE HUMAN EAR. 

paratively large membrana tympani, are not only con- 
densed upon the small membrana fenestra ovalis, but are 
importantly increased in their transmission through this 
interesting chain of bones. 

The exact influence the muscles of the tympanum 
exert, in regulating the vibrations of the membranes and 
the bones, is not ascertained. The general opinion is, 
that they are voluntary, being supplied with nerves 
from the portio dura, and that the membrana tympani is 
tightened or relaxed at will, as the sound may be pleasing 
or discordant : more correct observations however show, 
that they all, and particularly the tensor tympani, received 
especial branches from the otic ganglion, besides twigs 
from the tympanic plexus, and thus they may be sup- 
posed to be involuntary, and to be acted upon sympa- 
thetically, through the medium of nervous connexion 
with the portio mollis : resembling the influence of the 
retina upon the muscular fibres of the iris. This forms 
an interesting problem for solution, probably both opi- 
nions are correct ; as the muscles are supplied from the 
two sources, — from the voluntary system by the portio 
dura, and from the ganglionic by the chorda tympani, 
and the otic ganglion, — is it not probable that they may 
be of the mixed character, acting involuntarily when the 
acoustic nerve is over-excited, or when the mind is other- 
wise engaged, and attention not directed to the protec- 
tion of the membrane and of the ear in general ; and beingf 
influenced by volition, when the individual is desirous to 
increase or to diminish his mental perceptions? 



Section IV. 

The Internal Ear, or the Labyrinth, as it is termed 
from its complexity of organization, constitutes the Ear 
proper (PL IX., figs. 6, 7, 8, 9); the divisions hitherto 
treated of, being merely subordinate appendages. It 
contains the pulpy expansion of the acoustic nerve, to 
accommodate the requisite extent of which the labyrinth 
is formed of canals or tubes, curiously curved, and all com- 
municating with a central enlargement, the vestibule. 



VESTIBULE. 



61 



These canals are formed in the internal portion of the 
pars petrosa, and are entirely concealed in the adult; 
whilst in infancy, this portion of the temporal bone being 
incomplete, a part of their outline may be distinguished. 
The osseous canals contain a membranous labyrinth, 
exactly corresponding to themselves, except in the vesti- 
bule, where some variety occurs : thus has this division 
of the Ear been arranged under the heads of Osseous 
Labyrinth, and Membranous Labyrinth. 

It is therefore purposed to describe, first, the bony ca- 
nals, and then to allude to the membranous. 

The Bony Labyrinth is sub-divided with much advan- 
tage into the vestibule, the three semicircular canals, and 
the cochlea. The vestibulum occupies nearly the centre ; 
the semicircular canals are placed behind and external ; 
whilst the cochlea is in front and internal to the vestibule, 
so that the labyrinth is placed obliquely as regards the 
skull. 

The Vestibule is situated immediately on the inner side 
of the tympanum, rather posterior to the centre, the two 
cavities communicating in the dried bone through the 
fenestra ovalis. It is an oblong excavation, rather larger 
than a decorticated grain of barley; and is bounded in 
front by the cochlea, behind by the semicircular canals, 
and internally, by a cribriform plate of bone, situated at 
the bottom of the meatus auditorius internus, through 
which one division of the portio mollis passes. An osseous 
ridge runs along the vestibule, partially dividing it into 
two fovese or depressions ; the posterior, which is the 
larger and oval, is termed the fovea elliptica, or cavitas 
ovalis, into this depression the semicircular canals open ; 
the anterior and the smaller being somewhat semicircular 
is termed fovea, or fossa orbicularis, or hemispherica ; it 
communicates with the cochlea ; the posterior oval sulcus 
forms inferiorly a third, sometimes described under the 
term of fovea sulciformis. Besides the fenestra ovalis 
and the cribriform foramina already noticed, the vestibule 
has five openings at the upper and back part, from the 
semicircular canals ; a larger one leading into the cochlea 
at the lower and fore part ; and generally a small one at 
the posterior surface, which is the commencement of the 
aquseductus vestibuli. 

8 



62 



ANATOMY OF THE HUMAN EAR, 



The Semicircular Canals constitute the posterior and 
most extensive part of the labyrinth. Each canal forms 
at least three-fourths of a circle ; the most extensive is 
the superior, vertical, or anterior, which passes trans- 
versely across the petrous portion : its convexity being 
upwards, forms an eminence on the superior wall of the 
bone ; the anterior crus is enlarged into an ampulla, and 
the posterior uniting with the upper crus of the oblique 
canal, forms with it a common tube opening into the 
upper and back part of the vestibule. The posterior, oblique, 
or inferior, is next in extent ; it occupies the posterior 
part of the pars petrosa, and is placed lengthways as re- 
gards the bone, with the convexity turned outwards ; one 
crus being superior, communicates with the posterior of 
the vertical ; the other crus being inferior, is enlarged 
into an ampulla, and opens into the lower and back part 
of the vestibule. This canal, which is sometimes called 
the posterior or inferior vertical, nearly completes a 
circle. The external or horizontal is the shortest and 
largest of the three, and is also placed lengthways, its 
convexity being outwards, and its two crura on the same 
level ; the anterior crus forms a slight ampulla, and com- 
municates with the vestibule, immediately below, and 
external to the opening of the vertical, while the poste- 
rior opens external to, and below the common canal. The 
canals are not exactly round, but flattish, and are about 
half a line in diameter, being a little enlarged at the ex- 
tremities, independently of the ampullae. 

The Cochlea, named from its resembling a snail's shell, 
is the most intricate division of the labyrinth, of which 
it forms the anterior and outer part. When its walls are 
exposed without opening its interior, by cautiously filing 
away the petrous bone, it is seen as a well-marked pyra- 
mid, with the base opposed to the meatus auditorius 
internus, and formed by a cribriform plate of bone, per- 
forated with beautiful regularity, for the admission of 
vessels and nerves ; the apex, which is somewhat rounded, 
is inclined outwards and a little downwards, in such a 
manner that the whole structure is not quite horizontal. 
A little further removal of the bone will expose the out- 
line of the tube. The cochlea is a spiral conical canal, 



COCHLEA. 



63 



making two and-a-half turns round a central pillar ; and 
as the pillar is a cone, the spiral tube is most extensive 
at its base, and becomes gradually and proportionally 
diminished both in length and diameter to its apex. The 
central pillar, which is termed the axis, — and in conse- 
quence of its supposed resemblance to the nave of a 
wheel, the modiolus, — is a hollow cone, its base formed 
by the lamina cribrosa, and its apex again a little en- 
larged, forming a second smaller cone, termed the infun- 
dibulum, the two are thus united by their apices. The 
base of the infundibulum is surrounded and formed by 
the apex of the Cochlea, which, when examined inter- 
nally, presenting much the appearance of a dome, has been 
called the cupola : the walls of the pillar are extremely 
thin, and perforated, especially towards the base, by very 
many minute openings which transmit vessels, and par- 
ticularly nerves, to the spiral tube. 

Commencing at the inferior and posterior part of the 
base of the modiolus by a large opening from the vesti- 
bule, and from the inner surface of the promontory, the 
spiral canal makes its first, largest, and longest turn along 
the inferior to the anterior, and then the superior and 
posterior parietes to the second turn ; whence it continues 
winding outwards to the apex, and the last half turn ter- 
minates under the Cupola, — the canal becoming gradu- 
ally smaller as its extent diminishes. The spiral tube is 
subdivided into two scalae, or gyri, by a septum called 
the lamina-spiralis, taking the same spiral direction ; this 
septum is complete at the commencement of the canal, 
where it forms a part of the inferior and anterior wall of 
the vestibule, but is incomplete at the apex, not extending 
so far as the canal ; it there terminates in an unciform 
process, hamulus cochlea?, beneath the cupola, beyond 
which the two scalse uniting into one, form the canalis 
scalarum communis. The Lamina Spiralis is partly 
osseous and partly membranous; from the wall of the 
central pillar projects a spiral ridge of bone about one 
fourth or a third across the canal, and which consists of 
two plates, between which the nervous fibrils pass to the 
membrane ; to this bony ridge a coriaceous fibrous mem- 
brane is attached, reaching to the inner surface of the 



64 



ANATOMY OF THE HUMAN EAli. 



parietes of the canal and perfecting the septum; the 
membranous portion has received the name of zona 
cochkce. The osseous portion is more extensive in the 
first turn than in the succeeding. From this arrange- 
ment it is readily understood that one scala opens into 
the vestibule, and is therefore named the Scala or Gyrus 
Vestibuli ; and that the other, separated from the vesti- 
bule by the lamina spiralis, has its commencement imme- 
diately behind the membrane of the fenestra rotunda, 
by which alone it is excluded from the tympanum, and 
hence is called Scala or Gyrus Tympani. The scala 
tympani is the inferior, and throughout its extent the 
more capacious canal; its base especially presents an ob- 
ject of interest, as it may possibly at some future period 
lead to a better understanding of the use of the cochlea. 
(PL IX., figs. 8 and 9.) The lamina spiralis is here 
large, and runs backwards beyond the scala vestibuli, 
between the wall of the tympanum and the vestibule, to 
become attached to the margin of the fenestra rotunda 
internally, thus forming the parietes both of the vestibule 
and of the scala tympani; at this commencement of 
the scala tympani, the plate of bone common to it and 
the tympanum is enlarged outwards, forming the pro- 
montory already noticed, and consequently materially 
increasing the capacity of the scala, which will thus con- 
tain a little reservoir of fluid, influencing the degree of 
undulation and of the motion of the membrana secondaria 
— (membrana fenestrae rotundse). The scalse are often 
described, and perhaps correctly in reference to their 
physiology, as commencing from the vestibule, winding 
round the central pillar, turning back from the canalis 
communis round the hamulus cochleee, winding back 
again to the fenestra rotunda. It has been suggested by 
Ilg and others, that the central pillar or axis is ideal, and 
that it is merely the inner wall of the spiral canal, re- 
sembling as it were a hanging stair-case with closed 
banisters, which appears to be merely a difference in de- 
scription, for if we can imagine the closed banisters to be 
complete from the base of the flight of stairs to the ter- 
mination, a shaft would assuredly be formed, similar to 
the axis of the cochlea ; perhaps the term pillar does not 



AQUEDUCTS. g5 

exactly convey the impression intended, for it can hardly 
be considered a centre of support for the spiral canal, but 
as being necessarily formed by the union of their inner 
parietes, as a means of supporting the nerves and vessels. 
Allusion to the great similarity existing between the 
arrangement of the scalse of the cochlea, — their com- 
mencement, course, termination, and mode of union, with 
the stupendous shaft of spiral steps leading from Snargate 
Street to the heights at Dover, and down again, can 
hardly be refrained from ; it would almost appear pro- 
bable that the architect who planned that wonderful 
work, was acquainted with, and took as his model, this 
still more wonderful contrivance of the cochlea. 

The aqueducts of Cotunnus, even at this day, by some 
physiologists, are esteemed of considerable importance in 
the production of hearing, whereas they appear, from the 
careful investigations of Ribes, to be merely osseous 
canals transmitting blood-vessels and lymphatics ; they 
are two in number, the Aqicceductus Cochlece, which, pro- 
ceeding from the scala tympani very near to the fenestra 
rotunda, passes backwards under the labyrinth, and per- 
forating the bone, terminates by an irregular opening 
about the middle of the lower margin of the posterior 
surface of the petrous portion ; in this course it enlarges 
and communicates with many smaller canals which issue 
from the cancelli. The Aquceductus Vestibuli proceeding 
from the inner part of the vestibule, near the common 
opening of the superior and posterior canals, perforates 
the bone in the concavity of the former, and descends to 
the posterior surface of the pars petrosa near the jugular 
fossa ; this canal also enlarges in its course, and receives 
many smaller passages; it can sometimes be traced only 
as far as the cancelli around the vestibule, and some 
anatomists describe it as occasionally opening into the 
scala vestibuli. Cotunnus, and most anatomists after 
him, among whom may be mentioned Meckel, have de- 
scribed these aqueducts as being lined by a reflection of 
the membrane of the labyrinth, forming a communication 
between that membrane and the dura mater, by which 
it was supposed the fluid would recede during its undu- 
lations; they are, however, found to be entirely occupied 



QQ ANATOMY OF THE HUMAN EAR. 

by vessels proceeding to and from the labyrinth and 
bone, the veins terminating in the internal jugular, and 
perhaps also the absorbents, and the arteries being de- 
rived from those of the dura mater. It is possible that 
the lymphatics may, by active absorption, prevent over 
accumulation of the fluid. 

The Aquceductus Fallopii is misnamed, being an osse- 
ous canal for the purpose of transmitting the important 
portio dura, and protecting that nerve in its course ; this 
passage is unconnected with the organ of hearing, further 
than by passing in its neighbourhood, and being perfo- 
rated by some of its nerves. Commencing at the upper 
and inner part of the bottom of the meatus auditorius 
intern us, the Aquseductus Fallopii passes outwards, at 
first a little upwards and forwards, then backwards and 
downwards, and lastly almost directly downwards to the 
foramen stylo-mastoideum, which forms its termination ; 
in this course it is lodged between the external semicir- 
cular canal and the fenestra ovalis, surrounding the upper 
and back part of the tympanum. At its superior part it 
receives the hiatus Fallopii or foramen innominatum, a 
narrow canal on the upper surface of the pars petrosa, 
and which conducts the Vidian nerve to the portio dura. 
It is also perforated by several openings in its descent, 
which transmit the chorda tympani and other nerves to 
the tympanum. 

The Meatus Auditorius Internus, through which pass 
the Portio Mollis, Portio Dura, Portio Intermedia, and 
Internal Auditory Artery, commences at the posterior 
surface of the petrous portion of the temporal bone ; it 
passes outwards and forwards, is about half an inch in 
length, and less than a quarter in depth, and is termi- 
nated by an osseous plate, intervening between it and the 
labyrinth. This plate is divided into two unequal por- 
tions by a transverse ridge, the upper, and considerably 
the smaller portion, presents an opening at its anterior 
part which forms the commencement of the aquseductus 
Fallopii ; and at its posterior part are numerous small 
foramina, through which pass the filaments of one divi- 
sion of the portio mollis to reach the superior semicircu- 
lar canal. The lower and larger portion has also two 



MEMBRANOUS LABYRINTH. 



67 



divisions, the anterior of which forms a very regular 
cribriform plate, — circle of foramina being within circle, 
to the centre, which is occupied by one opening larger 
than the rest ; through these perforations passes a division 
of the nerve to the cochlea, the plate being in fact the 
base of the modiolus ; the posterior division also transmits 
filaments of nerves to the vestibule, and to the ampulla 
of the posterior canal. The meatus is lined by a reflec- 
tion of the dura mater. 

The bony labyrinth is exactly lined by a very delicate, 
and highly vascular periosteum, which secretes the Aqua 
Labyrinthi or the Perilymph of Breschet, described by 
Cotunnus, and which covers also internally the mem- 
branes of the fenestra ovalis and fenestra rotunda. Upon 
the inner surface of this delicate periosteum, in the scalse 
of the cochlea, the acoustic nerve is expanded, of a pulpy 
consistence, and is under the immediate influence of the 
fluid. 

The true Membranous Labyrinth is contained in the 
semicircular canals, and in the vestibule (PL IX., fig. 7). 
The Membranous Canals exactly correspond to the 
osseous, except in being much smaller, and in projecting 
a very little into the vestibule before they communicate 
with each other. The vestibular portion of the mem- 
branous labyrinth is composed of two sacs ; the larger 
and posterior, occupying the fossa ovalis, is termed the 
Utricle or Sacculus Vestibuli, and into it open the semi- 
circular canals ; it is, however, the opinion of some con- 
tinental anatomists that the inferior crus of the posterior 
canal communicates with the smaller sac. It is worthy 
of remark that the canals near their Ampullae lie, for a 
very short distance, upon the surface of the Sacculus 
before they open into it. The smaller sac is anterior and 
occupies the fossa hemispherica, it is sometimes termed the 
Sacculus, when the larger will be called the Sinus or Al- 
veus Utriculosus. The smaller sac is certainly closed 
towards the cochlea, and Meckel and some others, even 
regard it as an isolated little pouch, being closed on every 
side, whereas other authorities consider it to communicate 
with the commencement of the posterior canal, and Dr. 
Roget in his Bridgewater Treatise, describes the two sacs 



68 



ANATOMY OF THE HUMAN EAR. 



as freely opening into each other. It appears that the 
posterior surfaces of the sacs are adherent, by fine cellu- 
lar tissue, to the periosteum of the vestibule, but that the 
anterior surface, where opposed to the fenestra ovalis 
and to the scala tympani, is free and surrounded by 
fluid. 

The Membrane is very thin and of a whitish colour ; 
upon it are expanded the pulpy extremities of the nerve, 
which are most abundantly spread over the ampullse. 
"When the nerves first reach the membrane they are 
fibrous, and then gradually assume a semimucous consist- 
ence. The membranous canals and vestibular sacs are 
completely distended with a thin serous fluid, resembling 
that contained in the osseous canals, and which is occa- 
sionally called the Liquor Cotunni, to distinguish it from 
the surrounding perilymph ; though Cotunnus was not 
acquainted with the existence of the two fluids. Blain- 
viile has termed it "Yitrine Auditive" from its resem- 
blance to the vitreous humour ; as, however, Scarpa de- 
scribed this liquid correctly it might be named after him. 
Thus, then, the acoustic nerve being expanded upon the 
membranous labyrinth, is suspended between two fluids. 

Breschet, and after him Dr. Roget, have described and 
depicted a white calcareous body in" each of the vestibular 
sacs, which, according to the latter, " seems to be sus- 
pended in the fluid contained in the sacs, by the inter- 
medium of a number of nervous filaments, proceeding 
from the acoustic nerves." The author has several times 
sought for these bodies in the human Ear, but hitherto 
unsuccessfully, except perhaps in one instance; and 
upon inquiry he cannot ascertain that any of his anatomi- 
cal friends have seen them, though he is aware that they 
are now frequently alluded to. As they are so very 
generally met with in the lower animals, yet most proba- 
bly not universally in mammalia, it is possible that some- 
thing of the kind may exist even in the human subject, 
and it is certain that a whitish matter is often found upon 
the surface of the membrane ; though these bodies cannot 
however be of that great importance in the economy of 
the organ, always influenced through an atmospheric 
medium, and furnished with such an elaboration of ap- 



NERVES. 59 



pendages, as they are in animals whose medium of audi- 
tion either varies or is extremely dense, and whose appen- 
dages, if they exist at all, are merely rudimentary. 



Section V. 

The Nerves connected with the Ear require rather more 
than mere enumeration; inasmuch as the physiology of 
the nervous system, founded, as it always ought to be, 
upon its anatomy, is now engaging the particular atten- 
tion of medical philosophers. As it happens in the for- 
mation of the nervous system, as of every structure of the 
animal body, that each atom is deposited from the arteries 
in its own proper place, it becomes incorrect to describe 
the nerves as arising or growing from any one part : these 
cords should rather be traced, as Serres, Solly, and others 
have done, in the direction they transmit, the impressions 
they receive ; thus the auditory nerve should be consi- 
dered as proceeding from the Ear backward to the brain, 
and the facial, on the contrary, from the brain outwards 
to the face. This matter is, however, of much less im- 
portance than many persons seem to imagine, it being 
now perfectly understood, that the nerves do not grow 
from their place of attachment like a vegetable from its 
roots: for the sake of convenience, the nerves of the Ear 
may therefore be traced in the ordinary manner from the 
brain, the dissection in that direction being more easily 
performed. 

The Acoustic Nerve or Auditory (Plate X., fig. 2), is 
the eighth of the brain, though, until lately, from the time 
of Willis, it was reckoned as the soft division or portio 
mollis of the seventh pair, simply in consequence of the 
facial nerve passing through the foramen auditivum with 
it, though the attachment to the brain, the termination, 
structure, and function of each very widely differ. The 
Auditory Nerve has two attachments to the medulla ob- 
longata : thus the anterior is affixed to the inner side of 
that prominence which forms the fourth ventricle, and has 
been named the Corpus Pyramidale Posterius ; whence it 
passes outwards in front of the Corpus Restiforme, to unite 

9 



70 ANATOMY OF THE HUMAN EAR. 

with the posterior division : this last proceeds from the 
lower part of the fourth ventricle by four or five white 
striae, and winds behind the corpus restiforme, which is 
thus included in a groove between the two portions. The 
nerve thus formed, passes outwards and a little forwards 
through the foramen auditivum internum to the bottom 
of the meatus, accompanied and slightly grooved on its 
anterior and inner margin by the facial. It here divides 
into at least three sets of filaments ; the superior pass 
through the upper foramina behind the opening of Fal- 
lopius' aqueduct, and are chiefly distributed to the am- 
pulla of the superior semicircular canal, sending branches 
downwards to the vestibular sacs ; the inferior generally 
pass through the bone in two divisions, — the larger and 
upper going into the vestibule, to supply its sacs and also 
the horizontal canal, particularly its ampulla, the smaller 
and lower reaching the ampulla of the posterior canal ; 
the largest portion of the nerve passes through the base 
of the modiolus, which it traverses, and in its course sends 
numerous filaments through the pores to be expanded in 
a very regular manner upon both surfaces of the mem- 
brane of the scalse : the terminal branch distributed to 
the infundibulum, being the largest. All the filaments 
are at first fibrous and strong, and afterwards become soft, 
acquiring somewhat the character of mucus. It is worthy 
of remark, that the ampullse are much more abundantly 
supplied than the rest of the canals. The Auditory is a 
nerve of peculiar sense, being impressed only by one 
agent. 

The Facial Nerve, Seventh Cerebral, or Portio Dura, 
(Plate X., fig. 2), is distinctly a motor nerve, distributing 
its bulk to the muscles of the face ; yet as it has some 
connections with the Ear, it may be alluded to in this 
place. This nerve is usually described as arising from 
the groove between the corpus olivare and corpus pyra- 
midale, immediately below the pons varolii, which, how- 
ever, is merely its point of emergence ; for it may be 
traced inwards, and found to be attached to the motor 
tract by two bands ; one proceeding from that part within 
the pons varolii, runs outwards in front of the sentient di- 
vision of the fifth ; the other, commencing from the motor 



VIDIAN NERVE. 7 J 

portion of the corpus restiforme, passes behind the same 
division of the fifth, and unites with the preceding. The 
nerve thus formed, traverses the meatus internus, lying 
upon the internal and anterior margin of the auditory ; it 
then enters the canal of Fallopius, through which it 
passes to the Parotid Gland. Along the posterior border 
of the facial, resting upon the auditory nerve, is a distinct 
band, proceeding from the groove of the medulla oblon- 
gata, and termed Portio Intermedia or Facialis Minor, 
the principal nerve being then called Portio Major ; this 
portion is readily seen in the dead subject, and is well de- 
picted by Arnold ;' in the meatus it sends two twigs to 
unite with the portio mollis, whilst the bulk of the nerve 
passes on to that gangliform enlargement of the portio 
dura, which is situated on its first posterior curve ; from 
this enlargement two twigs pass backwards, to be also 
connected with the acoustic nerve. Swan has likewise 
noticed the connection between the facial and auditory 
nerves, but has not so minutely described it as Arnold : 
the former thinks that by this union the impression of 
sound may be communicated to the brain without the in- 
tervention of the Ear, through the medium of the facial 
ramifications. From the swelling of the facial nerve a 
minute twig runs forwards to the foramen ovale, and ap- 
parently reaches the otic ganglion. Near this point the 
nerve receives the Vidian or Nervus Innominatus, which 
is merely united by its sheath, and does not form with it 
a common nerve. The Facial in its course through the 
bone gives a good sized twig to the tensor tympani, part 
of which reaches the Eustachian tube ; then a filament 
or two to the tympanic plexus ; next a branch to the sta- 
pedius ; and lastly, near the termination of the aqueduct, 
the vidian leaves it under the name of the Chorda Tym- 
pani (Plate X., fig. 2). 

This interesting nerve, the Vidian, or, as Arnold terms 
it, the Great Superficial Petrosal, appears to be subser- 
vient to general communication ; proceeding from Mec- 
kel's ganglion in common with a larger branch, which 
descends to the carotid plexus, its runs backwards into 
the cranium, through the pterygoid or vidian canal ; then 
along the hiatus Fallopii to the aqueduct, which it leaves 



72 



ANATOMY OF THE HUMAN EAR. 



to cross the tympanum between the long crus of the 
incus and manubrium of the malleus; it emerges at an 
opening in the fissura glasseri, and afterwards unites 
with the true gustatory, which it again leaves to commu- 
nicate with the submaxillary ganglion. In this course it 
forms manv communications, some of which are con- 
nected with the Ear: first, with the sympathetic in the 
carotid canal, than with the portio dura ; thirdly, it gives 
branches to the tympanic plexus ; fourthly, to the laxator 
tympani; fifthly, it receives a twig from the otic gan- 
glion ; sixthly, it joins the gustatory; and lastly, with the 
submaxillary ganglion, the branches from which supply 
the salivary glands in the vicinity. Although this ac- 
count of the vidian nerve is generally considered as 
correct since the description of H. Cloquet, yet Cruveil- 
hier denies its accuracy, asserting that the nerve not only 
comes in contact with the facial, but forms a part of it, 
and that the chorda tympani, being a distinct branch of 
the portio dura, forms a part of the gustatory. 

The Ganglion Oticum or Aariculare, was discovered 
by Arnold of Heidelberg, and was supposed by him to 
have the same connection with the muscles of the tym- 
panum as the lenticular ganglion is known to possess with 
the iris. It is a small, soft, reddish body, larger in propor- 
tion in the foetus, situated immediately below the foramen 
ovale ; it rests on the inner surface of the third division 
of the fifth, between it and the Eustachian tube, and 
immediately in front of the great meningeal artery ; this 
concealed situation was doubtless the cause of its remain- 
ing so long undiscovered. This nodule possesses the 
communicationsof a sympathetic ganglion, and distributes 
its branches in a similar manner. There maybe traced, 
1st, twigs of union with the superior maxillary of the 
fifth ; 2d, posterior branches, one uniting with the facial, 
another with the tympanic plexus, and particularly a 
large one to supply the tensor tympani; 3d, anterior 
branches to the soft palate and tensor palati ; and 4th, 
descending branches long and slender, to communicate 
with the chorda tympani, and especially the pterygoid 
nerve, while one accompanies the spheno-spinal artery to 
the carotid plexus, by which it becomes indirectly con- 



ARTERIES. 



73 



nected with the first cervical ganglion of the great sym- 
pathetic. This distribution will be better comprehended 
by a reference to the annexed copy of Arnold's plate 
(Plate X., fig. 1). 

The Tympanic Plexus was described by Jacobson, and 
afterwards denied to exist; but it appears to have been 
demonstrated by Lobstein. The plexus is situated near 
the promontory of the tympanum, and is formed by the 
union of twigs from the sympathetic nerve, otic ganglion, 
chorda tympani; and some anatomists enumerate also 
from the portio dura, and glosso-pharyngeus ; from the 
latter, by the nerve of Jacobson : the plexus supplies in 
particular the membrane of the tympanum, and the 
mucous membrane of the cavity and of the Eustachian 
tube, together with the other structures, as the muscles, 
&c. Arnold has also traced a branch from the Par Vagum 
into the tympanum, which appears to be distributed to 
the bones and muscles, and he thus ingeniously accounts 
for this peculiarity in the great nerve of respiration. In 
the very eariy periods of foetal life, when in obedience to 
the general type of animal formation, rudimentary bran- 
chiae or gills exist, the tympanum with its ossicles 
assists in forming these transient organs, and being of 
course at that time supplied by the par vagum, the 
twig still continues after the arrangement has disap- 
peared. 

The Arteries of the Ear are derived both from the Ex- 
ternal and Internal Carotid, but chiefly from the Basilar. 
From the external carotid are the Posterior Aural, sup- 
plying the auricle and meatus, and which gives off the 
Stylo-mastoid ; this latter passes through the foramen so 
named, and divides into numerous small branches, sup- 
plying the mastoid cells and the labyrinth, one branch in 
particular uniting with the Ramus Tympanicus of the 
internal maxillary, forms a coronet around the membrana 
tympani, upon the surface of which many ramusculi are 
ramifying. The Anterior Aural Arteries, two or three 
twigs from the temporal, supply the forepart of the auri- 
cle and the meatus, and anastomose with the posterior. 
The Tympanic Artery, from the commencement of the 
internal maxillary, passes through the glasserian fissure, 



74 ANATOMY OF THE HUMAN EAR. 

forms the coronary vessel above noticed, and supplies the 
cavity of the tympanum. There also proceeds an auri- 
cular branch from the occipital. From the internal caro- 
tid a branch comes off in the carotid canal, which runs 
backwards and outwards to the tympanum to anastomose 
with the ty mpanic and stylo-mastoid. The largest artery 
is the Internal Auditory, which arises from the Basilar, 
and runs outwards and forwards, through the internal 
meatus, along the under margin of the portio mollis, sup- 
plying the nerve in its course : at the termination of the 
meatus it divides into many branches w T hich accompany 
the nervous filaments into the labyrinth, the greater num- 
ber pass to the axis of the cochlea, and thence to the 
scalse. 

The Veins accompany the arteries, with the exception 
already mentioned. 

The Lymphatics, for the most part, accompany the 
veins in the ordinary manner, and pass to the nearest 
glands. 



PLATE X. 

Fig. 1. — View of the Otic Ganglion. — A. Left Side of the 
Cranium seen from within. B. Petrous portion. 
C. Ethmoid Plate. D. Turbinated bones. E. Carotid 
Artery. F. Internal Jugular Vein, a, Otic Ganglion 
sending its branches to the Tympanum, to the soft 
palate, and its descending twigs of communication ; 
b, Meckel's Ganglion ; c, Semilunar Ganglion ; 
d, Ophthalmic nerve ; e, Superior Maxillary ; f, In- 
ferior Maxillary ; g, Chorda Tympani ; h, Malleus j 
i, Incus. 

Fig. 2. — Acoustic and Facial Nerves. — A. Section of the 
Petrous bone. B. Meningeal Artery. C. Semilunar 
Ganglion ; a, Portia dura ; b, Portio mollis ; c, Portio 
intermedia, and its connections with the two former ; 
d, Enlargement of the knee of the Portio dura re- 
ceiving, e, The Nervous Innominatus, f, Chorda 
Tympani, g, Malleus, h, Incus, i, Tensor Tympani, 
k, Nervous filament from the Otic Ganglion. 



FZaZe 70 



J?i#./. 




Fig 2 




SOUND. 



75 



CHAPTER III. 

PHYSIOLOGY OF HEARING. 

Having, in the description of the Ear, made slight allu- 
sion to the supposed uses of the various parts, it remains 
for us now to take a general survey of the physiology of 
hearing ; through the medium of which function the mind 
is informed of the presence, movements, and many of the 
properties of bodies. It may be observed, that hearing 
and sight alone take cognizance of the relation and pro- 
perties of distant objects, whereas we become acquainted 
with near bodies through the combined assistance of these 
and the other senses, particularly that of touch. 

Section I. 

As Sound is not matter, and has no positive existence, 
it has always been considered a difficulty to lay down an 
unexceptional definition of it. It may be stated, however, 
that sound is an effect upon the sensorium, produced by 
certain vibrations of the particles of a medium more or 
less elastic or movable, which effect is produced through 
an organ of hearing ; the result occasioned by these vi- 
brations through any other organ is rather to be attributed 
to feeling than hearing. The vibrations or oscillations 
of matter can and do occur without causing sound, in 
order to produce which, it is necessary that the animal 
organ should be so arranged as to receive the impression, 
and the brain so constituted as to perceive the effect. It 
would further appear, that the vibrations must be of a 
certain character, and of a certain rapidity, to produce 
the effect, as mere oscillation often excites no sensible 
impression. Every matter which possesses elasticity, or 
the particles of which are capable of moving upon each 
other, will propagate sound in degrees of intensity 



76 



PHYSIOLOGY OF HEARING. 



and rapidity, varying according to the density of the 
body, and its capability of motion ; thus the earth, more 
dense than water or air, is not so good a conductor of 
sound, in consequence of its molecules possessing less 
mobility ; on the other hand, it is an excellent reflector. 

Sound is propagated through a fluid medium, by un- 
dulations or waves of the medium ; the sound itself does 
not travel from the sonorous body to the ear, but the par- 
ticles of atmosphere or water being displaced or urged 
onwards by the vibrating body, meet with a resistance 
from the next layer, and the particles flow back again, 
having in like manner influenced that layer, which acts 
upon a third and then recedes, and so on, undulation after 
undulation is formed, until becoming weaker and weaker 
they at last cease (Plate XL , fig. 1 ). The manner in which 
sound travels is not inaptly illustrated by the circular 
waves produced in still water by a stone falling perpen- 
dicularly into it, the waves being deep and powerful in 
proportion to their proximity to the stone, and to their 
small circumference, each circle increasing in extent and 
diminishing in power, until by the influence of friction 
and attraction they cease altogether ; or by the regular 
and diminishing undulations of standing corn, in conse- 
quence of an impression made upon the extremity of the 
line by a blast of wind. The undulations produced by 
sound are unlike these similies in not being merely hori- 
zontal, as they likewise form perpendicular circles, alto- 
gether taking a globular form, as far as the surrounding 
resisting bodies will admit. It is evident that an imagi- 
nary section of such spherical waves, proceeding from the 
centre to the circumference, will form a cone, with its 
apex at the sonorous body, and its base at the termination 
of the sound ; this cone, for the sake of convenience of 
description, is imagined to be made up of numerous rays, 
a ray being the smallest division into which the cone can 
be separated (Plate XI., figs. 2, 3). 

The laws by which the sonorous rays are regulated, are 
similar to those of light ; thus, each ray passes in a straight 
direction through the same medium : and separating from 
those originally in its immediate contact, they all diverge 
in arithmetical proportion, according to the square of its 



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DIVERGENCE OF SOUND. 77 

root ; that is, at the distance of two measures it will oc- 
cupy four times the extent, — at three nine times, — at 
four sixteen times, and so forth ; the sound thus occupy- 



PLATE XI. 

Fig. 1. — Shows the Radiation of Sound, diverging in arith- 
metical proportion. 

Fig. 2. — Sonorous Waves, a a. striking upon an obstacle, b. 
are reflected in the same direction, c c. as though 
they proceeded from a point, d. at similar distance 
on the opposite side of the reflector. 

Fig. 3. — A Section of the same Circle of Waves, forming a 
cone, and more clearly proving the angles of inci- 
dence and reflection to be the same. 

Fig. 4. — Represents the Reflection of Sound from two opposite 
concave surfaces, by which it is converged to a focal 
point. 

Fig. 5. — The influence of the Speaking Trumpet in condens- 
ing Sound, by reflection from its walls, in conse- 
quence of which the waves escape parallel from its 
extremity. 

Fig. 6. — The same Waves, falling upon the expanded sail of 
a distant vessel, are reflected to a focus, and dis- 
tinctly heard. 

Fig. 7. — The Reflection of Sound in its transmission through 
a cylindrical tube. 

Fig. S. — The same through a conical tube. 

Fig. 9. — The Divergence of Sound produced by its reflection 
from a convex body. 

Figs. 10, 11, 12, 13. — Musical Strings in vibration : the straight 
lines are the strings at rest — 10 would give the 
Fundamental note — 11 the first — and 12 the second 
Harmonics. — 13. Shows the real Motion when 
compounded of the other three. — a a a. Are the 
Nodal Points where the strings are at rest. (See 
Somerville on the Connection of the Physical 
Sciences.) 

Figs. 14, 15, 16, 17, are four of Chladni's Figures, showing 
the Arrangement of Sound, occasioned by the dif- 
ferent Modes of Vibration of a Plate of Glass, &c, 
corresponding to Musical Notes of various degrees 
of pitch. 

10 



78 



PHYSIOLOGY OF HEARING. 



ing a greater and greater space, becomes proportionately 
diminished in intensity, until at last it is imperceptible. 
Thus being acquainted with the amount of sound at a 
given place, by calculating its diminution when it has 
reached his ear, the engineer is enabled to form a tolerably 
correct estimate of the distance between him and the spot 
from whence the sound issues. Of these scattered rays, 
which form the base of a large cone, but few fall upon 
the Ear. 

Many simple experiments are daily performed to eluci- 
date the fact above stated, that matter, elastic or freely 
moving, only can propagate sound ; thus, a sonorous body 
evidently in action in a vacuum, even the partial one pro- 
duced by mechanical agency, as a bell in the exhausted 
receiver of an air pump, does not produce sound, there 
being no, or rather too few, particles of air to undulate 
sufficiently to influence the Ear; and in proportion as 
the air is readmitted, the ringing at first faint becomes 
louder and louder, and if the air be condensed, it becomes 
more distinct than under ordinary circumstances. This 
fact again may teach the philosopher to what height he 
has ascended above the earth's surface, for in exact propor- 
tion as the atmosphere becomes rarified, sound becomes less 
distinctly conveyed. " Saussure reports that a pistol fired 
on the summit of Mont Blanc, produced no greater report 
than a little Indian cracker would have done in a room." 
There is an admirable correspondence between the rare- 
faction of the atmosphere in elevated positions, and the 
organs of the animated beings which inhabit them. On 
the contrary, when the air is more than usually dense, 
and particularly if it be, as it generally is, at the same 
time calm, sound w T ill be more distinctly conveyed. 

The surrounding medium being of course the conduc- 
tor of sound to the animals which inhabit it, and as these 
media vary in this property, by making a very few observa- 
tions upon these differences, we shall be led to admire 
the consequent all-wise modification of the acoustic 
organ. 

The Atmosphere in virtue of the great elasticity, and 
the extreme mobility of its particles, is a conductor of 
sound, admirably adapted to the delicate and well developed 



RAPIDITY OF SOUND. 



79 



ears of mammalia; its molecules are easily compressed 
and displaced, and having influenced the globules im- 
mediately in contact with them, they as readily recover 
their natural condition and situation. As the elasticity 
of the air is definite under ordinary circumstances, so 
likewise is its capability of transmitting the sonorous rays; 
which capability depending, as we have seen, upon the 
density and equilibrium of the medium, will vary as 
regards the clearness and distinctness of the sound, though 
not as regards the rapidity of its passage, which will be 
considerably less than in denser matters, as water, and 
most solid bodies. 

According to Halley and others, sound travels through 
our atmosphere at the rate of 1142 feet per second, which 
is ten times faster than the most violent hurricane ; but 
the Dutch who experimented most accurately in 1823, 
make sound to travel 1089*42 feet per second, which 
nearly agrees with the estimate of the French. The 
mean 1090 feet, according to Sir John Herschel, or 363 
yards, is within a little of the truth ; the velocity is in- 
creased 1*14 feet for every additional degree of tempera- 
ture. In England sound travels about 9000 feet in eight 
seconds, 121 miles in a minute, 765 an hour, about three- 
fourths of the diurnal velocity of the earth's equator. 

It was found that the velocity of sound, determined by 
observation, exceeded what it ought to have been theo- 
retically, by 173 feet, or about a sixth of the whole 
amount, which La Place suggested might arise from the 
increased elasticity of the air, in consequence of a deve- 
lopment of latent heat during the undulations of sound, 
and calculation confirmed the accuracy of his views. 

The distance to which sound will be conveyed, depends 
upon a variety of opposing or favouring circumstances ; 
as a number of undulations passing in various directions 
producing confusion in the hearer, — the state of the at- 
mosphere, — the mechanical opposition of solid bodies, — 
and particularly an acute sense, w T ill appreciate sound at 
a distance quite imperceptible by one of ordinary sensi- 
bility, and it is known that certain animals are capable of 
hearing at a much greater distance than man. In con- 
sequence doubtless of the diminished elasticity of the air, 



80 



PHYSIOLOGY OF HEARING. 



it happens that fogs, rain and snow, obstruct the progress 
of sound ; whereas the surface of quiet water, and ice, 
increase its clearness and strength. This effect, it may 
be presumed, is produced by two causes, partly by the 
reflection from the surface of the water or the ice, and 
secondly by the vibration of their particles, the latter effect 
might be expected to be more perfect in the fluid, whereas 
the reflection would be more complete from the surface 
of the solid water. It is well known that by the side of 
a canal sound may be heard at an astonishing distance ; 
thus, Dr. Hutton heard distinctly a person read on the 
Thames near Chelsea, 140 feet distance, whilst he could 
hear the same voice on land only seventy -six feet ; Lieut. 
Foster in the Polar expedition, held a conversation with 
a man a mile and a quarter distant, across the harbour of 
Port Bowen when frozen ; Dr. Young says, at Gibraltar 
the human voice was heard ten miles off. 

According to Derham, guns fired at Carlscroon w T ere 
heard at Denmark, eighty or perhaps 120 miles distant. 
Dr. Hearn heard guns fired at Stockholm, ]80 miles off. 
The cannonade of a sea-fight between the English and 
Dutch in 1672, was heard across England, at Shrewsbury 
and Wales, upwards of 200 miles from the scene of ac- 
tion. This last is a very remarkable circumstance, and 
it is to be remembered that in all to which allusion has 
been made, the sound travelled for the greatest part of 
the distance along the surface of water. The fact that 
sounds are more distinct and clear, and can be heard at 
a greater distance by night than by day, appears to be 
due, not only to the greater stillness then existing, and 
to the sense being engaged with one sound instead of 
many, but as Humboldt has said, to the greater homo- 
geneity of the atmosphere, its density not then being 
affected by the partial variations in temperature. 

In consequence of sound requiring a definite time to 
reach the Ear, and light passing to our senses instanta- 
neously, — which ] 92,500 miles in a second may be con- 
sidered to be, — we are enabled to judge of the distance 
of a body at the same time luminous and sonorous; 
thus, we learn the distance of the thunder-cloud, by com- 
puting the time required for the sound to reach the Ear 



DISTANCE SOUND MAY BE HEARD. 



81 



after the lightning has been seen ; thus, the artilleryman 
ascertains tolerably exactly the distance of the enemy, he 
sees the flash and afterwards hears the report of the gun, 
and reckons accordingly. The mechanic, aware that 
sound travels faster than a solid body descends, having 
let a brick unintentionally fall from his lofty scaffold, 
calls lustily to passers by to escape the danger, while it is 
yet descending. 

Under the common circumstances of nature, water has 
been considered inelastic or incompressible, and though 
Sir H. Davy proved the fallacy of that dogma, the ex- 
treme amount of pressure required to produce even a 
slight condensation, is such as to justify the above gene- 
ral conclusion under ordinary occurrences ; therefore, it 
is hardly to be expected that in transmitting sound, its 
molecules suffer the least compression ; but that freely 
moving against each other, one layer will more completely 
displace the next, its recession will be more rapid, and 
thus the sonorous undulations will not only travel faster, 
but also make a much greater impression than those of 
the elastic atmosphere. The fact has long been known, 
the a noise which was moderate in the air, has been quite 
stunning under water; from the experiments of M. Col- 
ladon, made at the lake of Geneva, which seems to be 
admirably adapted for the purpose, it appears that under 
water sound travels 4708 feet per second, upwards of 
four times faster than in air ; and the increased strength 
is perhaps in the same ratio. The first Monro performed 
some interesting experiments in a lake near Edinburgh, 
and proved the same general results, though he did not 
arrive at M. Colladon's accuracy. We have noticed above 
the circumstance of sound being conveyed more clearly 
along the surface of water, in which instance it is most 
probable that the sonorous rays are increased in number, 
by reflection from the water's surface into the atmosphere ; 
but that the particles of the water also are affected, and 
assist in conveying the sound, seems proved by the fact, 
that under the influence of favouring conditions, two 
sounds reach the Ear with different rapidity, one con- 
veyed by the water, the second by the air. 



82 



PHYSIOLOGY OF HEARING. 



The most obtuse comprehension must be struck with 
the design of the Supreme Artificer, in rendering the 
circumambient fluid the means of conveying sound, and 
in adapting the organs, of the denizens of this fluid to its 
greater or less capability of performing this all important 
office ; what would be the result, if the inhabitant of the 
atmosphere possessed the ear of the fish ? The slighter 
influence of sound w r ould produce too little effect upon 
the vestibule and semicircular canals through the skull, 
to sufficiently influence the acoustic nerve, and hearing 
would be very partially if at all excited ; whereas if 
sonorous waves were communicated to the ear of a mam- 
malian, and particularly of man, through the medium of 
water, so stunning an effect would be produced, as to be 
incompatible with the due discrimination of sounds, and 
the healthy condition of the organ. 

Solids are also excellent conductors of sound, for re- 
sisting as they appear to be, vibratory motions take place 
in their particles, when under the influence of a sounding 
body : and in virtue of the density of the solid, the power 
of conduction will be greater even than in the fluid : 
thus, it is well known that the Ear placed in contact with 
one extremity of a long log of wood, will most clearly 
receive the impression produced at the other, by a slight 
stratch of a pin. The velocity is likewise very great; 
thus, for example, a blow struck at one extremity, will 
be distinctly heard at the other; first, by the Ear placed 
in contact with the wood, and soon afterwards by the 
other Ear, through the medium of the atmosphere ; and 
the same simple experiment may be performed by the 
aid of a brick-wall. An iron wire, several hundred feet 
in length, will afford a still more accurate example, for 
being a very dense body, its vibrations are smaller and 
more rapidly conveyed. It is calculated that sound 
passes through iron, and some wood, at the rate of 
18,530 feet in a second. It is also found that sound is 
more clearly conducted in the immediate vicinity of a 
straight wall, chiefly, no doubt, because the rays are not 
only prevented from diverging in that direction, but also, 
because being reflected from the hard surface, a greater 



REFLECTION OF SOUND. 



83 



number must reach the Ear; and it is also more than 
probable, that the vibrations of the wall itself may assist 
in producing this increased effect. 

Sound, however, is modified, by being conducted 
through different media ; thus, when excited in the 
atmosphere, it is but indistinctly heard by the diver 
under water ; and the angler may see the agitation of the 
water excited by the fish, but will not hear the noise pro- 
duced, unless the animal be near the surface ; thus again 
a wall will suffer but slight vibrations in consequence of 
the atmospheric sonorous rays, and we consequently hear 
the music of our streets but partially in our closed apart- 
ments, in which case the diminution of hearing will be 
in proportion to the thickness of the walls, and the per- 
fection of the windows. 

In describing the physiology of hearing, it is neces- 
sary, in order to be quite explicit, to allude to a most im- 
portant law, to which sound is subject in a manner very 
similar to light ; there is a near resemblance in the laws 
which regulate the sonorous vibrations and the matter of 
light ; if, indeed, light be matter, and if it be merely the 
vibrations of an ether, the same observations will still 
apply. They travel in the same direction, form the same 
spheres and cones, diverge in the same proportion, but 
proceed with infinitely different rapidity. But the law 
of Reflection, to which both light and sound are subjected, 
and precisely in a like manner, requires the especial at- 
tention of the physiologist, as the eye and the ear of the 
higher animals are adapted to produce these reflections, 
without which the function of neither organ would be 
accurately accomplished. It has been already seen that, 
in order to be a perfect conductor, a solid body must be 
the immediate recipient of sound from the sonorous pro- 
ducer, and not indirectly through a rarer medium ; thus, 
the rays travelling through the atmosphere, and striking 
upon a resisting solid, will doubtless produce a slight 
effect upon it, which effect will be regulated by the 
amount of resistance, but rarely sufficient to excite sound ; 
the atmospheric undulations will recede from the resist- 
ance, and the sound will travel back again exactly in the 
same manner as it originally proceeded from the produc- 



84 



PHYSIOLOGY OF HEARING. 



ing power, of course weakened in proportion to the dis- 
tance it has extended, and in consequence of its force 
being partly broken upon the surface (Plate XI., figs. 2, 
3). This reflection of sounds, is termed Catacoustics, in 
contradistinction to Diacoustics, which relate to sounds 
directly striking the Ear ; as in light so in sound, the 
angle of incidence and of reflection, are always equal; 
and by this simple geometrical law, the various pheno- 
mena may be accounted for ; the single ray only which 
falls in a straight direction upon the surface, w T ill be re- 
flected back to the spot from which it proceeded ; as every 
other ray of the cone must be more or less oblique in pro- 
portion to its proximity or distance from the centre, so 
will it be reflected with exactly a similar obliquity, and 
in precisely the opposite direction. It becomes therefore 
very evident, as each particle of a solid is really flat, and 
the ray or rays falling upon it will form with it their pe- 
culiar angle, that the general shape of the surface will 
vary the general reflection ; that projecting surfaces may 
be so arranged as to produce repetitions of reflections ; 
and that in a tube the rays will be thrown from one sur- 
face to the other again and again to their exit. A few 
examples will suffice for elucidation ; if sound falls upon 
a flat wall, it is reflected, but too few of the rays reach 
the Ear to produce an effect, or a noise only may be ap- 
preciated ; but if the wall should be angular, the sonorous 
rays reflected from each surface may meet and be so much 
increased in power, as to occasion an echo, which is a 
weakened repetition of the first sound : if the angular sur- 
faces be several, and so situated as to receive the reflected 
sound from each other, several echos will arise, each be- 
coming fainter than the preceding. There are many in- 
teresting examples of such repeated echos ; the Author 
counted nine, from the rocks at Lurlei Folsen on the 
Rhine, occasioned by the report of a pistol ; Herschel de- 
scribes the remarkable reflections under the Menai-bridge; 
those at the lakes of Killarney are well known : — in 
Woodstock-park an echo repeats syllables fifteen times 
by day, and twenty times by night. If the reflecting 
surface be concave, the rays will be directed from every 
part towards a focus ; if, on the contrary, it be convex, 



REFLECTION OF SOUNDS. 



85 



they will be still further diverged (Plate XL, figs. 4, 6, 
9) : thus an echo is sure to occur from the walls of a cir- 
cular apartment ; and if it have also a dome, a focus w r ill 
be formed somewhere near the centre, rendering the 
building exceedingly inconvenient for the purposes of 
speaking, as is frequently witnessed in the theatres of 
the Medical Schools. As a circle is an union of numer- 
ous small planes, so will the sound be reflected from 
plane to plane, completely round the building, and an 
Ear placed against one part of it, will distinctly receive 
the impression produced by a mere whisper in another, 
constituting one form of the whispering gallery. In a 
perfect whispering gallery, many rays, reflected from va- 
rious surfaces, meet in one point or focus, and give rise 
to a strength of sound, which seems almost incompatible 
with the original. The alcoves on Westminster-bridge 
afford an instance of this kind ; a whisper at the focal 
point of one alcove, which is near the centre of the para- 
bola, supposing it to be complete, will be readily heard 
at the focus of the opposite alcove, across the bridge, the 
sound having then undergone two reflections. " In the 
cathedral at Girgenti, in Sicily, the slightest whisper is 
borne with perfect distincness from the great western door 
to the cornice behind the high altar, a distance of 250 feet. 
By a most unlucky coincidence, the precise focus of di- 
vergence at the former station, was chosen for the place 
of the confessional. Secrets never intended for the pub- 
lic ear thus became known, to the dismay of the confessors, 
and the scandal of the people, by the resort of the curious 
to the opposite point, (which seems to have been disco- 
vered accidentally,) till at length, one listener having had 
his curiosity somewhat over-gratified, by hearing his 
wife's avowal of her own infidelity, this tell-tale peculi- 
arity became generally know T n, and the confessional was 
removed." The Navigator, hailed from a ship, far too 
distant for ordinary intercourse, places himself in the so- 
norous focus of his expanded sail, and holds ready com- 
munication with his interrogator similarly situated, 
though at a distance of several miles (Plate XL, figs. 5, 
6). These examples might be indefinitely multiplied ; 
but sufficient has been stated, for the mere purpose of 

11 



86 



PHYSIOLOGY OF HEARING. 



elucidating the influences of the animal organ upon sound. 
Allusion may, however, be made to the vast importance 
of attention to the laws of acoustics, on the part of the 
architect, in erecting a building for public speaking, or 
for music ; very few of such erections are w 7 ell adapted 
to the purposes intended. In the beautiful church of 
St. Sepulchre, the audience would lose half the sentences 
of the Preacher, were it not for the large concave reflector 
placed immediately behind the pulpit, which, although 
of great general utility, occasionally produces an almost 
ludicrous variation in the tone as the speaker changes his 
position, (a) 

(a) The reflection of sound is well described in the follow- 
ing paragraph of Midler's Physiology, (American Edition, 
1843), p. 750: — 

" In relation to their reflection, the undulations of sound re- 
semble those of light ; in passing from one medium into another 
different one, they are in part reflected, and in part only propa- 
gated onwards. The ticking of a watch placed in the focus of 
a concave mirror may be heard in the focus of another mirror 
placed so as to receive and concentrate the reflected sonorous un- 
dulations. It is owing to sonorous vibrations of air being pro- 
pagated with more facility in that medium than they are im- 
parted from it to solid bodies, that sounds are transmitted in their 
full intensity through tubes, just as on the same principle solid 
rods propagate sonorous vibrations to great distances almost 
without any loss of intensity. A speaking- trumpet represents a 
parabola, in the focus of which the sound is excited. Being re- 
flected by the parabolic surface, the sonorous undulations are all 
thrown in a direction parallel to the axis of the parabola. The 
cause of the increased intensity given to the sound by the speak- 
ing-trumpet is, for the most part, the coincidence of newly ex- 
cited undulations with others already reflected, producing undu- 
lations with greater condensations and rarefactions. But the 
resonance of the confined mass of air in the tube also contributes 
to this effect ; for the air of a tube open at both extremities, while 
it propagates sound, also becomes the seat of resonance. The 
ear-trumpet becomes narrower towards the ear, and consequently 
concentrates the sonorous undulations. If its walls have the para- 
bolic form, and the focus of the parabola be at a point near the 
ear, sonorous undulations coming in a direction parallel with the 
axis of the parabola will of course be brought to a focus near the 
ear. (Eisenlohr, loc. cit., p. 164.) If a reflecting surface is situ- 
ated so as to throw sonorous undulations upon the ear, and is at 



INFLUENCE OF TUBES UPON SOUND. 



87 



The animal physiologist would rather dwell upon the 
reflection of sound through tubes ; for though every per- 
son may not agree with the author that such an effect 
occurs in the meatus auditorius, yet no one doubts the 
necessity of a tube varying in length and dimensions to 
produce the almost infinite modulations of voice. The 
reflection of sound occurs from the sides of a tube, in a 
manner similar to that from a concave surface, the angle 
of incidence and that of reflection being equal; the inte- 
rior being a circle, the rays are thrown from every part 
to the opposite surface, and thus the reflections are mul- 
tiplied in proportion to the length and dimensions of the 
tube : hence the longer the instrument the more numer- 
ous will be the reflections, and the deeper and fuller the 
note. All the holes of the flute being closed it becomes 
a long tube, and the low note is sounded ; the first finger 
being raised the tube is shortened, the air rushes out of 
the opening, and a high note is the consequence. The 
human windpipe affords an excellent example of the same 
instrument, the deep tones are only to be produced by 
lengthening the tube from the lower end of the trachea 
to the lips, which are also protruded, the larynx being 
likewise expanded ; and to give a high note the singer 
throws back his head, retracts his lips, shortens his 
pharnyx, diminishes the rima glottidis, and lessens the 
trachea. Without doubt the variation in the diameter 
of the vocal apparatus will have the chief influence, but 
the trachea and pharynx importantly assist in the opera- 
tion by varying their length. 

The shape of the tube must have an important influence ; 
if it be of the same size throughout, the sound will be 
simply condensed and strengthened by the reflections ; 
if it be tapering like a flute, the angles will become more 
and more acute, and the note deeper, the sound being in- 
such a distance that the reflected undulations reach the ear per- 
ceptibly later than the undulations coming direct from the sound- 
ing body, an echo results, which is perfect when the difference 
of time is so great that the two series of undulations strike the 
ear at perfectly distinct periods." 



gg PHYSIOLOGY OF HEARING. 

creased ; if on the contrary it be conical, the apex receiving 
the sound and the base giving it exit, as in a speaking 
trumpet, the angles will be less and less acute, till the 
last may be even obtuse : thus the exact dimensions of 
each section of such instruments becomes a matter of vast 
importance (Plate XL, figs, 5, 7, 8). 

Tubes of wood, metal, glass, &c, are not merely con- 
ductors of sound by preventing the rays from diverging, 
and increasing their power by reflection, but the molecules 
of the instrument themselves vibrate, and that in harmony 
with the sound introduced, becoming thus indeed musi- 
cal, though varying in their perfection. The musical 
sound is, however, rather to be attributed to the influence 
produced upon the column of air contained in the tube, 
than to the reflection of the rays thrown into it, and the 
vibration of the instrument. It becomes very evident, 
therefore, that tubes by preventing sound from being lost 
in the air by expansion, must conduct it to an almost 
indefinite distance ; hence, the great utility of speaking- 
pipes to convey the slightest sound from one apartment 
to another. M. Biot, at one end of the iron conduit, 3120 
feet long, laid down to supply Paris with water, distinctly 
heard the lowest whisper made at the other ; he was then 
also afforded an additional proof that notes of different 
pitch pass with equal rapidity. Water poured from a 
jug into Carisbrook well, in the Isle of Wight, which is 
210 feet deep and twelve in diameter, and having the 
interior lined with smooth masonry, produces a report 
almost approaching to thunder. 

A few observations may suffice with respect to the 
causes producing sound ; whatever thus operates must do 
so by throwing the medium into a vibratory motion, and 
this is effected in various modes : for instance, by sud- 
denly displacing a portion of the fluid, as of the air, by 
clapping the hands, or of the clouds by the escape of 
electricity in thunder storms; in these instances the 
matters displacing the air are also vibrating, by which, 
the effect will be increased. 

The most usual and interesting cause of sound is the 
vibration of solid bodies, communicating to the conduct- 



CAUSES OF SOUND. 



89 



ing medium the same number and character of undula- 
tions. From what has preceded it will be understood, 
that the denser the solid the more perfect will be its 
vibrations, and the more perfectly will they influence the 
conducting medium ; and as the atmosphere is the me- 
dium with which we are most conversant, the future 
remarks will have reference to that alone. The more 
completely the solid is condensed, or the smaller the 
space it occupies, provided the quantity is not lessened, 
its motions will be the more rapid ; but in order to pro- 
duce the most perfect effect a very dense body of small 
size, as a metal wire, should be stretched between two 
points. It is apparent that the more tensely this cord is 
drawn, the more dense becomes the material, and smaller 
in size, and in the same degree will be diminished its 
capability of vibrating through an extensive space ; con- 
sequently just in an equal proportion will be its increased 
number of vibrations, and the limitation of each ; in this 
manner is produced the acute sound, or the high note. 
Again, the thicker and longer wire of less dense material, 
and less tightly drawn, will vibrate slowly and through 
a more extensive space, producing less effect, and thus 
the grave sound or low note is occasioned. It is gener- 
ally understood that the more tense the wire the more 
rapid are the vibrations, and that the metal may be tight- 
ened even to rupture, producing still the same effect; it 
is, however, very probable that the wire may be so 
arranged as to vibrate so rapidly, and through so small 
an extent, that it shall produce a note too high to be ap- 
preciated by the human Ear, a theory which Professor 
Wheatstone has applied to the membrana tympani. The 
wires and strings of musical instruments differ in density, 
in size, in length, and in tenseness ; and the perfection of 
arrangement would be to vary the same wire in the above 
particulars so rapidly, that it might give rise to a great 
variety of notes ; this is attempted to a certain degree as 
regards the length and the tenseness, and with consider- 
able effect, but as that is insufficient, numerous strings 
or wires differing from each other are used. The human 
larynx, though probably chiefly a wind instrument, affords 
the best example of what a stringed instrument should 



9Q PHYSIOLOGY OF HEARING. 

be to accomplish a great variety of tones, but art cannot 
imitate such perfection. 

Probably no wire, however short and tense, nor an 
instrument of any kind, produces one single set of oscil- 
lations, that is, that it at once vibrates throughout its 
entire extent ; but, as is most evident in strings of mode- 
rate length, one section is vibrating while another of very 
small extent termed the Nodal point, is at rest ; the sec- 
tions above and below which, are moving in opposite 
directions, and thus oscillating waves run along the wire 
in both directions from the point touched, the whole 
length of the string truly performs its vibration, but each 
section has besides its independent motion ; these com- 
bined motions run up and down the string, producing 
interferences with each other, which assist, with the fric- 
tion of the air and the specific gravity of the material, to 
reduce it to r a state of rest (Plate XL, figs. 10, 11, 12,13). 
The harmony of the sound is importantly connected with 
the number and rapidity of the oscillating sections, of the 
nodal points, and of the interferences, and most interest- 
ing disquisitions are given of them in the various treatises 
on the science of music, to which it would be incompati- 
ble with the object of this essay further to allude.(a) 

(a) -Under the head of undulations of inflexion or flexion- 
waves in solid bodies, we read in Muller (op. cit,, p. 746) : — 

" If a stretched cord or string of a musical instrument is struck, 
not at its middle, but near one extremity, an extension of it is pro- 
duced at this part, and is communicated as a wave or oscillation 
to the whole cord, travelling from one end to the other where 
it is reflected back again like the undulations of fluids. 

" If the cord or string is struck several times in succession, a 
regular series of undulations is produced, as upon the surface of 
water. The reflection of these undulations at the extremity of the 
cord, and the meeting of the incident and reflected undulations, 
give rw to the stationary vibrations ; and the parts of the cord 
which remain at rest between these stationary waves or vibra- 
tions are the ' nodal points.' 

" The simplest stationary vibration of a cord or string is, how- 
ever, that which results, not from the meeting of progressive 
undulations, but from the transverse vibration or movement 
from side to side of the whole cord between its fixed extremi- 
ties, which here constitute the nodal points. This kind of vibra- 



NODAL POINTS. g^ 

It is not at all requisite that the body vibrating so accu- 
rately as to constitute a musical instrument, should take 
the lengthened form, every shape will answer the pur- 
pose, provided it does not too nearly approach that of the 
cube, but the shape will modify the oscillations and con- 
sequently the notes produced, which are further influ- 
enced by the peculiarity of the matter used, and thus 
very different sounds may proceed in harmony from a 
great variety of instruments. 

The vibrating material may be a plate of glass, 
of metal, or a sheet of parchment ; the latter being 
stretched over an oscillating cylinder constitutes the 
drum in its different forms. These bodies also vibrate 
partially, having their nodal points or lines which are 
at rest. M. Savart, by many experiments, has proved 
that the vibrating portions of a plate of glass will form 

tion is induced most readily by striking a string with the ringer, 
or with a violin-bow. The transverse oscillation of solid bodies 
which do not owe their elasticity to tension, such as metal rods 
fixed at one extremity only, is also an instance of stationary 
vibration. 

" Stationary undulations or vibrations are produced also when, 
by touching lightly a stretched string, we give rise to a nodal 
point in that situation, and then strike the part of the string 
thus isolated. If, for example, the string is touched at its middle, 
and either its upper or lower half then struck with the violin-bow, 
not merely does the half that is struck become the seat of trans- 
verse vibrations, but the other half also vibratesfrom side to side, 
though in the opposite direction. The number of the vibrations 
in a given time is in this case twice as great as when the string 
vibrates in its whole length, and the sound produced is the oc- 
tave of the fundamental note of the string. If the string is 
touched at the point of junction of its first and middle third, a 
nodal point is formed between its middle and last third also, and 
the number of the vibrations is three times as great as that of the 
vibrations of the entire string within the same period. In the 
same way, by isolating and striking a fourth or fifth of the string, 
a regular division of the string into four or five vibrating por- 
tions, separated by nodal points, is induced. Pieces of paper 
placed upon these nodal points during the vibration of the string 
are not thrown off. The sounds resulting from the vibration of 
a string thus divided by nodal points are called * harmonic 
notes.' " 



92 PHYSIOLOGY OF HEARING. 

triangles, squares, circles, semicircles, and indeed as- 
sume a great variety of shapes and forms, the neighbour- 
ing portions being of corresponding forms and at rest 
(Plate XL, figs. 14, 15, 16, 17). That this arrangement 
into portions at rest, and in vibration takes place, may be 
variously proved, as by running the wetted finger in dif- 
ferent directions along the surface of the glass, or metal, 
or drum-head, — by carrying a bow across the margin, — 
by striking the surface in certain points and with a cer- 
tain degree of force, in which cases the light particles of 
sand which have been previously scattered upon the plate 
or parchment, w T ill arrange themselves upon the lines at 
rest in exactly corresponding forms. This circumstance 
is most usefully applied by engineers, who, when they 
anticipate, in the progress of a siege, the working of a 
mine beneath, although the noiseless caution of the enemy 
prevents any sound reaching the Ear, even when placed 
in contact with the ground, are able to discover the prox- 
imity and direction of the works below, by the mode in 
which the grains of fine gunpowder oscillate and arrange 
themselves, when scattered upon the face of a well-tuned 
drum, which has been placed in a position favourable to 
be influenced by the slight vibrations of the solid earth. 
Is it not possible that such partial vibrations, with their 
nodal lines, occur in the Membrana Tympani, assisting 
in the production of the infinite variety of sound known 
to take place ? 

Another excitant of sound, of great interest to the 
animal physiologist, is a narrow aperture, through which 
air is propelled with varying force, occasioning various 
notes, as the whistling of the air through the key -hole ; 
although in this instance the chief cause is the force of 
the current through a mere aperture, yet it is more than 
probable that the slight vibrations of the lips of the open- 
ing will also modify the effect. The perfection of such 
an instrument will be in proportion to the degree of vari- 
ation in the size of the aperture, of the resistance and 
elasticity of its lips, and consequently of their vibratibi- 
lity, to the varying force with which the air is propelled 
through the opening ; and if to these advantages be super- 
added an elastic and vibrating tube, changing its length 



THE INFLUENCE OF APERTURES. 93 

and diameter according to the note to be produced, a 
musical apparatus of almost infinite variation will be the 
result. As examples may be mentioned the clarionet, 
flageolet, pipe, and flute with the appendage of the vibra- 
ting lips of the performer. In the organ and Pandean 
pipes the want of variation in the tube is supplied by 
many pipes differing in length and size, with similarly 
arranged apertures, the air being thrown alternately into 
one or the other, occasioning the harmony required. Of 
all examples, however, the animal apparatus, and par- 
ticularly that of the human being, is alone perfect ; and 
when directed by a highly educated intellect, can pro- 
duce every sound in nature, within the capacity of its 
strength, and very many which are not by other means 
to be formed. The uncivilized man's power of varying 
sound is comparatively very limited, though far exceed- 
ing that possessed by other animals, or that can be pro- 
duced by other means, natural or artificial. Thus it 
happens that the invention of speech is perfected in pro- 
portion to the civilization of the community ; the air is 
readily vocalized in its passage through the trachea, and 
particularly the larynx, but its further all-important 
modification in its transmission through the fauces, 
month, and lips, to constitute speech, requires a certain 
degree of advancement in intelligence and tuition. 

Kratzenstein, and Kempelen, and later, Mr. Willis of 
Cambridge, have endeavoured to imitate the human voice, 
by adapting cylindrical tubes to a reed, the length ofwhich. 
can be varied at pleasure, by sliding joints : and to a cer- 
tain extent they have succeeded, being enabled to pro- 
nounce by these contrivances the vowels at a different 
pitch, by drawing out the tube, whilst air was forced 
into it from the bellows of an organ. It is an interesting 
fact, that " when the pitch of the reed is very high, it is 
impossible to sound some of the vowels, which is in per- 
fect correspondence with the human voice, female sing- 
ers being unable to pronounce u and o in their high 
notes." 

The vibrations must be of a certain duration to give 
rise to sound, and according to the very beautiful experi- 
ments of M. Savart, to which further allusion would be 

12 



94 



PHYSIOLOGY OF HEARING. 



misplaced on this occasion, it appears that sixteen single 
vibrations in a second occasion the lowest sound that can 
be heard ; before these experiments were performed, it 
was supposed that twenty-four were required. The same 
philosopher has proved that the human ear can appreci- 
ate a sound occupying the twenty-four-thousandth part of 
a second; i. e., that twenty-four thousand vibrations of a 
musical chord in a second of time, will produce the high- 
est note which can be recognized. It was also formerly 
stated that 8,000 or 20,000 vibrations in a second formed 
the highest note that could be heard ; of course it follows 
that the intermediate number of vibrations will be more 
distinct. From a variety of experiments, Dr. Wollaston 
concluded that human hearing is limited to nine octaves, 
extending from the lowest note of the organ to the highest 
known cry of insects ; he adds, that " as there is nothing 
in the nature of the atmosphere to prevent the existence 
of vibrations, incomparably more frequent than any of 
which we are conscious, we may imagine that animals, 
like the Grylli, whose powers appear to commence nearly 
where ours terminate, may have the faculty of hearing 
still sharper sounds which we do not know to exist, and 
that there may be other insects hearing nothing in com- 
mon with us, but endowed with a power of exciting, and 
a sense which perceives, vibrations of the same nature, 
indeed, as those which constitute our ordinary sounds, but 
so remote, that the animals who perceive them may be 
said to possess another sense, agreeing with our own solely 
in the medium by which it is excited." 

It would be misplaced here to allude to musical sounds, 
— to that beautiful harmony, at one time exhilarating and 
at another soothing to the human mind, the capability of 
appreciating which, it would appear, was a mean de- 
signed by an all beneficent Providence, to augment the 
happiness of mankind, to allay feelings perturbed and 
prejudicial, and to encourage that calmness and resigna- 
tion requisite to their peace both here and hereafter. We 
may, however, be permitted to conclude these remarks 
with one or two further observations upon the variety of 
sounds. 

The loudness of sound depends upon the extent of vi- 



VARIATION OF SOUNDS. 



95 



bration, and not upon its rapidity, thus the high or low 
note may be loud or otherwise, (a) The difference of 
acute and grave sounds constitutes the pilch, which is a 
most important property in language whether in talking 
or in singing. " By the association of different notes, we 
have all the results of melody and harmony in musical 
sound ; and of intonation and modulation of the voice, of 
accent, cadence, emphasis, expression, passion, in speech. 
The song of birds, which is one of their principal modes 
of communication, depends chiefly for its distinctions and 
its significance upon the combinations of the acute and 
grave." From the different relations of the number of 
vibrations in a second arise all the differences of musical 
intervals, concords, and discords. The term quality of 
sounds is given to notes of the same pitch produced by 
different instruments ; thus, if a stringed and a wind in- 
strument be in unison, and the same note sounded, the 
difference is still striking. This variety of quality, which 
is so very distinctive of different animals, and which dis- 
tinguishes the voices of different persons, is evidently of 
much importance, as it connects the voice with the indi- 
vidual, and is indeed almost requisite, in order that lan- 
guage may become a medium of intercourse. 

The sympathy of sounds arises from the vibrating bo- 
dies of different instruments being drawn up to the same 
pitch ; thus the atmospheric undulations occasioned by 
the tone of a chord of the piano or iEolian lyre, will ex- 

(«) "Resonance" says Muller {op. cit., p. 749), " is a means 
of rendering a sound louder than it is as produced by the sound- 
ing body itself. It consists in increasing the extent of surface of 
a soniferous medium similar in kind to the sounding body. 
Hence the increase of sound produced by placing a vibrating 
tuning-fork upon a solid body. The influence of the bridge and 
sounding-board of stringed instruments is due to the same prin- 
ciple. Greater resonance is, however, produced by an insulated 
body than by one which has no circumscribed surfaces ; for an 
insulated body reflects back a part of the undulations within it 
at its borders and surfaces, and, these reflected undulations meet- 
ing with the undulationsnewly excited in it, an increased extent 
of the excursions of the oscillating particles, answering to the in- 
creased height of the elevations of flexion- waves, is produced 
{ Weber, p. 536)." 



96 



PHYSIOLOGY OF HEARING. 



cite the vibration of a harmonious chord of a harp in a 
distant part of the room, having crossed the strings, out 
of concert with the originator of the sound, without in the 
least affecting them. The effect of this sympathy of 
sounds is extremely delightful when produced by several 
iEolian harps conveniently hung on the branches of trees, 
in a quiet evening, with occasional gentle breezes. May 
not the membrana tympani be drawn into harmonious 
sympathy with many sounds that strike upon its surface. 

The quality of the human voice is dependent chiefly 
upon the capacity and elasticity of the larynx, and is 
modified into articulation during its further passage by 
the cavity of the mouth, and the surrounding organs. 
'■■ The articulate character of sounds is for mankind one 
of the most important arrangements which exist in the 
world ; for it is by this that sounds become the interpre- 
ters of thought, will, and feeling, the means by which a 
person can convey his wants, his instructions, his pro- 
mises, his kindness, to others ; by which one man can 
regulate the actions and influence the convictions and 
judgments of another. It is in virtue of the possi- 
bility of shaping air into words, that the imperceptible 
vibrations which a man produces in the atmosphere, 
become some of his most important actions, the founda- 
tions of the highest moral and social relations, and the 
condition and instrument of all the advancement and im- 
provement of which he is susceptible." 

This wonderful power of speech, the grand preroga- 
tive of mankind, could not have been invented without 
an Ear of the utmost delicacy to catch the infinite variety 
of sounds, and a Sensorium to perceive and reflect upon 
the impressions communicated through the organ. It is 
therefore all gratifying to trace the correspondence of 
development in the organs of speech and of hearing to 
their perfect condition in man, and whilst admiring, to 
adore the wisdom of the Divine Designer. 



INFLUENCE OF SOUND UPON THE EAR. 97 



Section II. 

INFLUENCE OF SOUND UPON THE EAR, 

Of the sonorous rays that fall upon the auricle, some 
are, no doubt, reflected into the atmosphere ; but with 
this exception, the sound striking upon the eminences 
is thrown into the cavities and grooves, and, increased 
in strength by reflection from the parieties, is conducted 
to the bottom of the concha, and probably this reflec- 
tion particularly occurs from the inner surfaces of the 
tragus and antitragus. These prominences protect the 
meatus under ordinary conditions ; and in the lower mam- 
malia are raised to expose the opening for the reception of 
a greater quantity of sound ; or are drawn more closely 
down for increased protection, as the will may be acting 
upon either the elevating or depressing muscles. Hence 
it follows, that the auricle is not merely the recipient of 
a larger quantity of sound, than would otherwise fall upon 
the meatus, but likewise that the rays are thereby con- 
densed towards a focal point. 

Though we cannot consider with Itard, that the ex- 
ternal Ear is of no importance to the economy of hearing, 
nor with Buchanan, that the power of the function de- 
pends much upon its size and configuration ; yet we 
cannot but consider it to be of considerable utility ; the 
observations already made upon the outer ear of ani- 
mals, as well as its greater development in the savage, 
where this part is unconfined by dress and habit, may 
direct us to comprehend the advantage it yields. The 
Author cannot but refer to the opinion of an intelligent 
friend, Mr. Swinburne, — that the ' auricle, at the same 
time that it will reflect some of the sonorous waves to the 
meatus, will in consequence of its structure prevent their 
reflection, and, as it were, absorb them, and thus diminish 
rather than increase their influence : to which opinion he 
was lead by the different effects produced, when the 



93 PHYSIOLOGY OF HEARING. 

auricle had accurately adapted to it plates of different 
metals and other materials. 

The sound, thus influenced, passes along the meatus 
auditorius externus, and strikes upon the surface of the 
mernbrana tyrnpani. In consequence of the animal tem- 
perature the rapidity must be increased, but so very 
slightly, as not to be ascertainable, and probably produc- 
ing neither inconvenience nor advantage. As in any 
other tube the sonorous rays will be reflected from the 
surface of the canal, and consequently increased in power 
by condensation ; and it is evident that the peculiar 
curved direction of the conduit will occasion the reflec- 
tions to be such, that they shall fall with the greatest 
advantage upon the membrane, the obliquity of which 
structure admirably adapts it to receive them. Some 
further benefit than the mere yielding tendency of the 
outer portion of the canal is possibly derived from its 
being partly cartilaginous and partly osseous, in the 
greater degree of vibration possessed by the outer, and of 
reflection by the inner portion. Nor can we omit to 
allude to the diminution, of the reflection, which other- 
wise might amount to an echo, that is caused by the 
cerumen. 

The Mernbrana Tyrnpani receives the sonorous rays 
prepared by the outer Ear, and exercises an important 
influence in propagating their effect to the sensorium. 
It is not a regular concavity, and hence probably does 
not possess a focus of reflection ; its reflecting power is 
also limited by its fibrous irregularity ; and it is therefore 
well adapted for vibration. Stretched between two layers 
of an elastic medium, the air without and that within 
the cavity, the membrane receiving its oscillations from 
the one must freely communicate them to the other ; 
those excited in the inner stratum of air may react upon 
the membrane ; which, thus vibrating between the two 
powers, might not «be well adapted to receive the new 
impulse in continued though varying sound : hence it 
is more than probable, that the membrane is merely re- 
turned, by the reaction of the air in the tympanum, to its 
condition of quiescence. The ossicula auditus, with their 
ligaments, forming an elastic chain, are well arranged to 



INFLUENCE OF THE MEMBUANA TYMPANI. 



99 



receive the motions from the membrane, and the impulse 
having been conveyed onwards to the labyrinth, they 
will react upon the membrane to the degree only of nor- 
mal replacement. Thus, an excellent provision appears 
to be made, to prevent the membrane being driven too 
far outwards, and to preserve it in a condition to be in- 
fluenced by new sounds, as rapidly as they can be con- 
veyed to it. This membrane therefore is a drum-head 
modified, and, like that instrument, has a mass of air, oc- 
cupying the interior, furnished with an aperture, the 
Eustachian tube, probably for recession; and, like the 
drum-head, it can be tightened or relaxed, possessing 
however the very great advantage of its relaxation or 
tenseness varying according to the note falling upon it, 
and as rapidly as it receives it. It is most likely that the 
number of vibrations of which the membrane is capable 
vary at least from 16 to 24,000 in a second, as such a va- 
riety of vibrations of a chord can be distinguished ; and 
it is further probable, that many slower or more rapid 
oscillations of this structure may occur, which do not 
produce an appreciable effect. Of course, the muscles 
have an important influence in adapting the membrane 
to this great variety, as this power depends upon its de- 
gree of tension. It appears that when the mind is intent 
upon catching every minute impression, the tensor tym- 
pani and the stapedius, by drawing the ossicula inwards, 
give tension to the membrane, and thus fit it to receive the 
slightest influence. On the contrary, when the note is 
oppressively loud or discordant, the laxator tympani, 
aided by the levator tympani, relaxes the membrane, and 
thus lessens its vibrativeness.(a) Professor Wheatstone 



(a) Muller {op. cit., p. 756) has proved, by a variety of expe- 
riments, that a moderately lax state of the membrana tympani 
is more favourable to the transmission of sound than when it is 
very tense. A great tension of the membrane causes, however, 
as Dr. Wollaston has shown, chiefly deafness in grave sounds. 

"These facts," says Muller, " admit of a practical application 
in pathology. It is not very rare to meet with persons who are 
deaf to the more grave sounds only, while they still hear dis- 
tinctly acute sounds, even though they be not loud. One of my 



-L00 PHYSIOLOGY OF HEARING. 

has said, that the complete tension of the membrane will 
limit, if not remove its power of vibration, and that conse- 
quently in sounds, which would be productive of danger 
to the organ, or unpleasantness to the mind, the tensors 
are in fullest action, and the impression is prevented. It 
has been noticed that this does not harmonize with the 
general opinion, and unfortunately the Author cannot 
place his hand upon the experiments upon which the Pro- 
fessor founds his conclusions. Do the muscles act in con- 
sequence of the impression communicated to the brain, 
which then transmits to them its volition ? It is impe- 
rative that sensation shall be first perceived by the sen- 
sorium — is this in fact a mental action, excited for the 
protection and function of the membrane ? Without en- 
tering upon the interesting question of muscular action, 
we may yet be permitted to state what appear to be facts, 
susceptible of satisfactory proof. The otic ganglion was 
imagined by its discoverer, Arnold, to influence those 
muscles in a manner similar to that which the lenticular 
exerts upon the iris, and doubtless this is correct; but if 
he implied, which he appears to have done, that this influ- 

colleagues, who is deaf, hears acute better than grave sounds. 
In such cases it is very probable that the membrana tympani is 
in a state of too great tension. In the present state of obscurity of 
the diagnosis of diseases of the ear, this hint may be of some 
use. Such unnatural tension of the membrana tympani may, 
of course, be produced by several different causes. It may arise 
from occlusion of the Eustachian tube ; in which case the air in 
the tympanum may either be expanded by the heat of the body, 
and so force outwards the membrana tympani, or it may be par- 
tially absorbed, when the membrane would be pressed inwards 
by the air without. Another cause may be a contracted state of 
the tensor tympani muscle. In my colleague the Eustachian 
tube is free, for he can force air into the tympanum. When the 
Eustachian tube is closed, and the tension of the membrana 
tympani is the consequence of the expansion or partial absorp- 
tion of the air in the cavity of the tympanum, the operation of 
puncturing the membrane, or the mastoid process, may be easily 
conceived to be beneficial ; but when the too great tension of 
the membrana tympani, and consequent deafness, are owing to 
a contracted state of the tensor tympani muscle, the operation 
must be useless. This may in part account for the various re- 
sults obtained from it." 



INFLUENCE OF THE MEMBRANA TYMPANI. jqj 

ence was exerted through the sensorium, he was certainly 
in error, as the recent investigations of Dr. Marshall Hall, 
and Mr. Grainger, have proved. As in every other struc- 
ture of the body capable of receiving an impression, so are 
those upon the membrana tympani transmitted by the in- 
cident nerves to the grey matter of the otic ganglion ; 
this, being a seat of nervous power, is excited, and com- 
municates its influence, by the reflex motor nerves, to the 
muscles either of relaxation or tension as may be required, 
thus a most important action is brought about quite inde- 
pendent of the will. Again, by the medium of the nerves 
of common and peculiar sense, an impression is conveyed 
to the sensorium, upon the perception of which volition 
is communicated to the muscles by means of the portio 
dura, which are then excited to action in consequence of 
the operation of the mind. This double mode of action 
corresponds with the function of every muscle, there 
being two distinct exciting causes, one physical and inde- 
pendent of the mind, the other mental and occasioned 
by volition. By this beautiful and simple arrangement, 
the protection of the organ is placed beyond our control, 
and at the same time means are afforded us for influenc- 
ing its functions to our own conveniences. 

In reflecting upon the physiology of the membrana 
tympani, it is interesting to recollect that its chief muscle, 
the Tensor Tympani, is largely supplied, both from the 
otic ganglion and the portio dura, which circumstance 
alone would lead to the comprehension of its great uti- 
lity. It is more than probable that the membrane, by 
these means, is brought into a state of unison with the 
sounding body, whatever that may be ; and that if the 
attention be directed to a particular sound, the membrane 
being out of unison with other noises, they do not occa- 
sion that interference and confusion which otherwise 
would result. The late Mr. Swinburne carried this idea 
still further, by imagining that as each fibrous elevation 
of the membrane must, for the reasons before stated, differ 
from all the others in length, and it is possible even in 
density, it forms a musical chord of a particular note, the 
vibrations of which will only respond to a corresponding 
note ; and thus he ingeniously accounts for the circum- 

13 



102 



PHYSIOLOGY OF HEARING. 



stance of many sounds varying in note, quality, pitch, &c, 
being distinctly perceived at the same time by the mind, 
and without much if any confusion. In this manner the 
membrana tympani, receiving an exact impression of the 
vibrations of the sounding material, transmits them to 
the malleus, and possibly also to the air contained in the 
cavity. 

The Ossicula are so articulated that they form not only 
a vibratile, but also an elastic chain, and being firmly 
articulated to each other, are admirably arranged to trans- 
mit the rapid and tremulous motions from the membrana 
tympani to the membrana fenestrse ovalis. They assist 
also in increasing the power of the impression, as nearly 
the whole vibration of the membrane is concentrated in 
the manubrium of the malleus, and is further augmented 
in its head by virtue of its leverage ; this augmentation 
of vibratory power is still increased in its transmission 
along the different levers, and at last is condensed upon 
the membrane of the oval opening, which thus, small as 
it is in comparison with that of the tympanum, receives 
the same influence much augmented ; this increased vi- 
bration is thence transmitted to the fluid of the vestibule. 
The degree in which these small bones are useful in this 
process has been variously stated ; some physiologists, 
imagining that they are of secondary importance in trans- 
mitting the oscillations, and others, in which opinion the 
writer concurs, considering them the chief means of oc- 
casioning the undulations of the aqua labyrinthi. It is 
true that the ossicula, not even excepting the stapes, may 
be lost, and hearing still continue, but the function is then 
imperfect, and the more minute sounds are impercep- 
tible, a much greater influence being required when the 
impression is made directly on the stapes, or on the mem- 
brane of the fenestra ovalis, to throw it into vibration, 
than when the bone or membrane is influenced through 
the natural means. If this argument is to be admitted, 
by the same reasoning we must suppose that the mem- 
brana tympani is of little importance, for when the bones 
are lost the membrane must be absent also ; and not un- 
frequently it happens that the great bulk of the membrane 
may be removed by ulceration, leaving only sufficient 



INFLUENCE OF THE OSSICULA. 1Q3 

to support the malleus, and yet the function may be but 
very little affected : and as a tympanum in its normal 
state is never met with in the animal series unaccompa- 
nied by the ossicula, or an ossiculum, there is reason to 
believe that they constitute the most important part of 
the middle Ear. Most probably it is through the agency 
of these small bones that the infinitely delicate, minute, 
and rapid vibrations of the membrane of the tympanum 
occasioned by speech, music, and all slight sounds fol- 
lowing in quick succession, are increased sufficiently to 
produce effective undulations in the labyrinth; thus, 
therefore, there is great reason to esteem the middle 
as the musical portion of the Ear. Savart concludes 
his observations upon the ossicula by saying, "In fine, 
I believe that the chain of small bones is to the Ear the 
same as the bridge to the violin. "(a) 

(a) " The ossicula of the ear are the better conductors of the 
sonorous vibrations communicated to them, on account of being 
isolated by an atmosphere of air, and not continuous with the 
bones of the cranium ; for every solid body thus isolated by a 
different medium propagates vibrations with more intensity 
through its own substance than it communicates them to the 
surrounding medium, which thus prevents a dispersion of the 
sound, just as the vibrations of the air in the tubes used for con- 
ducting the voice from one apartment to another are prevented 
from being dispersed by the solid walls of the tube. The vibra- 
tions of the membrana tympani are transmitted, therefore, by the 
chain of ossicula to the fenestra ovalis and fluid of the labyrinth, 
their dispersion in the tympanum being prevented by the diffi- 
culty of the transition of vibrations from solid to gaseous bodies. 
The membrana tympani being a tense solid body bounded by 
free surfaces, the sonorous undulations will be partially reflected 
at its surfaces, so as to cause a meeting of undulations from 
opposite directions within it ; it will therefore, by resonance, 
increase the intensity of the vibrations communicated to it, and 
the undulations thus rendered more intense will act in their turn 
upon the chain of auditory bones." 

" The propagation of sound through the ossicula of the tym- 
panum to the labyrinth must be effected by undulations of con- 
densation and rarefaction of their particles only, not by oscillations 
of the entire bones, even in cases where the entire membrana 
tympani oscillates ; for, if the stapes were in its vibrations alter- 
nately more nearly approximated and removed from the laby- 



1Q4 PHYSIOLOGY OF HEARING. 

It is necessary to allude to other influences which are 
exerted by the tympanum. Many physiologists regard 
the air of the cavity as the chief means of transmitting 
the vibrations from the membrane of the tympanum to 
the labyrinth, by exciting similar oscillations in the mem- 
brana fenestras rotundas ; the use of the ossicula, accord- 
ing to this theory, being principally limited to supporting 
the membrane, and in some degree to assist in affecting 
the labyrinth through the medium of the fenestra ovalis. 
In this manner the supporters of this opinion account for 
the loss of the bones being unattended with what may 
be considered to be a corresponding loss of audition : and 
for the use of the extension of the tympanic cavity, by its 
communication with the cranial cells. In this argument, 
however, it appears to be forgotten that the loss of the 
stapes is generally attended by complete deafness, as far 
as concerns the tympanum ; that the membrana fenestras 
rotundas is disadvantageously situated to receive the ful- 
lest influence from the air of the tympanum ; and that 
the communicating cells are fewer and smaller in man 
than in most other animals, though he enjoys the nicest 
discrimination of sounds, far surpassing that even of birds. 
It is nevertheless probable that the elastic air may act 
upon the membrana secondaria, or membrane of the fenes- 
tra rotunda, and thus assist in producing the undulations in 
the scala tympani; yet to the writer it appears more con- 
sonant with the arrangement of the cochlea to suppose, as 
will presently become more apparent, that it merely re- 
stores the membrane to its natural condition of quiescence, 
when it has been thrown into a state of oscillation by the 
fluid within ; that, in fact, the air influences the two 
membranes, that of the tympanum, and that of the round 
opening, in a like manner, though acting upon the inner 
surface of the one, and the outer of the other, maintaining 
a pressure upon both equal to that which opposes it, thus 
affording each an opportunity of freely oscillating. (a) 

rinth, the fluid of the latter cavity must necessarily be very 
compressible. The extent through which the individual parti- 
cles affected by the undulations oscillate equals very minute 
fractions only of the length of the stapes." (Miiller, op. cit., 
p. 754-5.) 

(«) " The necessity for the presence of air on the inner side 



INFLUENCE OF THE TYMPANUM. 



105 



The atmosphere contained in the tympanum becomes 
rarefied by the temperature of the part, for in proportion 
as it becomes expanded by the heat, it may be absorbed, 
and as it will consequently cease to afford the requisite 
counter-pressure, and suffer a diminution in its capability 
of vibrating, a constant renewal of fresh air is demanded ; 



of the membrana tympani, — in other words, the necessity for 
the existence of the tympanic cavity, — to enable the membrana 
tympani and ossicula auditus to fulfil the objects which we have 
described, is obvious. Without this provision neither would the 
vibrations of the membrane be free, nor the chain of bones 
isolated, so as to propagate the sonorous undulations with con- 
centration of their intensity. But while the oscillations of the 
membrana tympani are readily communicated to the air, in 
the cavity of the tympanum, those of the solid ossicula will 
not be conducted away by the air, but will be propagated 
to the labyrinth without being dispersed in the tympanum. 
Equally necessary is the communication of the air in the tym- 
panum with the external air through the medium of the Eusta- 
chian tube for the maintenance of the equilibrium of pressure 
and temperature between them." (Miiller, op. cit., p. 755.) 

As respects the relative importance of the sonorous vibrations 
made in the two fenestra?, Miiller holds the following lan- 
guage : — 

" We may express the problem to be decided in other words, 
thus: By which succession of media is the intensity of sonorous 
undulations least diminished ? — by air, a tense membrane, an 
insulated and moveable solid body, and water ; or by air, a tense 
membrane, air, another tense membrane, and then watery fluid ? 
The experiments which I have instituted prove very clearly 
that — 

" Vibrations are transmitted with very much greater in- 
tensity to water when a tense membrane, a chain of insulated 
solid bodies capable of free movement, are successively the con- 
ducting media, than when the media of communication between 
the vibrating air and the water are the same tense membrane, 
air, and then a second membrane ; or, to apply this fact to the 
organ of hearing, that the same vibrations of the air act upon 
the fluid of the labyrinth with much greater intensity through 
the medium of the chain of auditory bones and the fenestra 
ovalis, than through the medium of the air of the tympanum and 
the membrane closing the fenestra rotunda. 

" I imitated the structure of the tympanum and reached 
the above result by direct experiment." (p. 759.) 



106 



PHYSIOLOGY OF HEARING. 



this is readily effected through the medium of the Eus- 
tachian tube, the closure of which is invariably attended 
with a loss of the function of the tympanum. It is very 
probable also that a slight recession of the air may take 
place, from the cavity along the tube corresponding to 
each vibration of the membrane ; — to entertain which 
opinion it must be supposed that the oscillations of the 
membrane are too rapid for the elasticity of the air. In 
consequence of the large size of the tube in the reptile, 

— its communicating with the blow-hole of the whale, 

— and deaf persons frequently opening their mouths when 
in the act of listening, it has been imagined that in man 
sounds may pass by this mode also into the Tympanum 
and excite Hearing. The truth of this supposition is more 
than doubtful ; were the sound to proceed in this direc- 
tion, it would strike upon the inner surface of the mem- 
brane, and oppose its natural action ; and the anatomical 
arrangement will not permit the belief, that the small 
bones can be influenced without vibration of the mem- 
brane ; and in order that this effect may occur in the 
whale, the bones are indirectly attached to the membrana 
tympani. Richerand has accounted for the well known 
fact of individuals who are deaf, opening the mouth when 
intent upon Hearing, by supposing that the depression 
of the jaw expands the meatus ; this enlargement, how- 
ever, if it occur at all, is very slight, and can have but a 
very limited influence. The writer has noticed that 
persons deaf from accidental disease of the external or 
middle ears, rarely thus open their mouths ; and as deaf- 
ness from loss of function of the nerve, is frequently con- 
nected with deficient mental capacity, this symptom may 
perhaps be attributed to the same cause. The fact of 
the Eustachian tube constituting an excretory duct to 
the tympanum has already been alluded to. [a) 



{a) " The principal object for the fulfilment of which this tube 
exists, wherever there is a tympanum, appears to me," says Muller, 
* to be the maintenance of the equilibrium between the air within 
the tympanum and the external air, so as to prevent inordinate 
tension of the membrana tympani, which would be produced by 
too great or too little pressure on either side, and the effect of 



INFLUENCE OF THE TYMPANUM. 



107 



It is difficult, perhaps impossible, to attribute an use 
'to the mastoid cells, to which an objection may not be 
easily raised ; it is thought that they allow a reverberation 
of the air, and thus add to its effect upon the membranes ; 
and this is particularly the opinion of those who consider 
the air as the conducting medium from one membrane to 
the other. It seems probable that, as regards the Ear, 
their chief use is to contain a large quantity of air, which 
is thus prevented from becoming too rapidly rarefied; 
reverberation may also aid in the performance of the func- 
tions already noticed. There cannot exist a doubt that 
the cells are beneficial, and in birds particularly so, by 
lessening the specific gravity of the bones ; and affording 
increased surface for muscular attachments. 

We have thus traced the influence of sound to the fun- 
damental portion of the organ, in which we find that vi- 
brations are excited in the two membranes of the fenestra?. 
It has been long imagined that the membrane of the oval 
opening set into action by the ossicula, and that of the 
round opening by the air of the tympanum, directly com- 
municate their oscillations to the aqua labyrinthi, which 
is in immediate contact with their inner surfaces ; and if 
it should be asserted that a sac of the liquor intervenes 
between the fluid and the membrane, the effect would be 
still unaltered. No doubt can exist that the first, and 
perhaps the most important, undulations take place in the 



which would be imperfection of hearing. It is not the increased 
or diminished density of the air on either side of the membrane 
which is of the chief importance, but the tension of the memhrana 
tympani which they necessarily produce, and which always in- 
terferes with the integrity of hearing. 

" It is on this principle that we must explain the good effect of 
catheterising the Eustachian tube, or of perforating the mem- 
brana tympani, or mastoid process of the temporal bone, in many 
cases of deafness caused by chronic occlusion of the tube. 
While, however, I maintain that this is the principal office of the 
Eustachian canal, I do not deny that it has other uses, of which 
the next in importance appear to me to be the modification of 
the sound so as to render it more clear, the supplying the tympa- 
num with air, and the discharge of the secretion of that cavity." 
(p. 760.) 



IQQ PHYSIOLOGY OF HEARING. 

vestibule, and as the large sac of this cavity is in direct 
contact with the membrane of the fenestra ovalis, another 
reason is afforded to presume that its influence is much 
greater than that of the fenestra rotunda. The fluid of 
the vestibule is thus agitated into undulations, most likely 
exactly corresponding to the vibrations of the membrane. 
And if it be a fact, that the vestibule contains two creta- 
ceous bodies suspended by nervous fibrillee, they must 
still further influence the fluid, at the same time that their 
oscillations must produce an effect immediately upon the 
acoustic nerve. These waves extend around the semi- 
circular canals, commencing from, and terminating in, the 
sac of the vestibule ; it is impossible to ascertain the course 
of the undulations along the canals, but judging from the 
analogy of the cochlea, they probably commence at the 
narrow aperture, and terminate in the ampullae ; and thus 
it will happen, that meeting with the agitated water of 
the vestibule, increased undulations will occur in the en- 
largements, corresponding to the greater quantity of ner- 
vous filaments there distributed. 

It has been generally stated that similar undulations, 
taking their course from the vestibule along the scala ves- 
tibuli of the cochlea, and from the membrane of the fe- 
nestra rotunda through the turns of the scala tympani, 
meet in the canalis scalarum communis, and immediately 
arrest each other. But from what has preceded, it will 
be collected that the author concurs rather in the view of 
Sir Charles Bell, that all the undulations are conveyed 
through the medium of the vestibule; and that from its 
smaller sac they are taking the course of the scala vesti- 
buii, passing through the common canal, and again de- 
scending from the apex to the base of the cochlea, along 
the scala tympani, and at length strike upon the inner 
surface of the membrana second aria, which yields in pro- 
portion to the power of the wave against it. In a man- 
ner somewhat similar to that in which the water con- 
tained in the ampullae of the canals is affected, the 
membrane, vibrating, influences still further the fluid in 
the much expanded base of this scala. Thus is scienti- 
fically accounted for the recession of the fluid necessarily 
consequent upon its undulations : in the same degree as 



INFLUENCE OF THE NERVES. JQ9 

the membrane of the fenestra ovalis is driven inwards, 
that of the rotunda is forced outwards, and the vibrations 
of both corresponding, the effect is maintained so long 
as the cause is applied. Cotunnus, and after him many 
other physiologists, believed that the fluid receded into 
the aqueducts named after that anatomist, but which are 
now ascertained to be veins ; as they are, however, some- 
what unusually large, it is possible that under extraordi- 
nary circumstances of over-accumulation of fluid, or 
excessive undulation, a very small quantity may flow 
into them. 

The aqua labyrinthi flowing thus over the highly 
nervous membrane excites an impression which is con- 
veyed by the acoustic nerve to the brain, and perception 
of the sound is the consequence. As the nerve in the 
semicircular canals is expanded between two columns of 
fluid, it is evident that it must be there more influenced 
than in the cochlea ; but the precise modification which 
these curiously curved tubes, constituting the labyrinth, 
produce, is not known : that they are subservient to per- 
fect hearing, and particularly to the discrimination of 
minute sounds, is certain, but to what amount will per- 
haps ever remain an unsolved problem. (a) 

Thus, at last, as in the lowest animals, so in the high- 
est, hearing is merely a very delicate and elaborate modi- 
fication of feeling; the pulp of the auditory nerve is 
mechanically affected by the water, which contact the 
brain feels ; but the impression is so far removed, by its 
extreme delicacy, from the common sensation of touch, 
that it appears to be another sense, requiring another 
term. 

A question may be here proposed : — Is this impres- 
sion communicated to the brain by other means than those 
above stated ? Most probably it is not ; for though a 
watch applied to the teeth or to the skull will excite sen- 
sation in a person said to be deaf, yet it is most likely 
that the labyrinth is healthy, and consequently the vibra- 
tions are received by its fluid, the disease being seated in 
the outer or the middle Ear. The portio mollis in the 

(a) See Muller, p. 765-8. 
14 



HQ PHYSIOLOGY OF HEARING. 

internal meatus, or in the skull, before its expansion into 
its pulpy matter, may, although it is hardly probable, be 
capable of receiving and communicating the impression, 
without the assistance of the rest of the organ ; but there 
is little or no doubt that the sensation which is perceived 
in cases of complete nervous deafness through the me- 
dium of the skeleton, is rather to be considered as the 
product of the common nerves of feeling. 

The connection existing between the Portio Mollis, 
Portio Dura, Portio Media, and Ganglion Oticum, can be 
better accounted for by considering it necessary to sym- 
pathetically combine the functions of the muscles and 
other structures of the tympanum with that of the ner- 
vous expansion of the labyrinth, than by adopting Mr. 
Swan's supposition, that the facial nerve can receive and 
transmit sound to the auditory. 

The benefit consequent upon our being furnished with 
two ears is, in addition to the general advantages of all 
the animal organs being double, that we may the better 
ascertain the direction of the sound, and thus more ac- 
curately be informed of the situation of the sounding 
body. 

As certain colours do not impress the retina sufficiently 
to be perceived by the brain, so certain sounds, according 
to Dr. Wollaston's interesting investigations, are inaudi- 
ble to some persons, although readily heard by others. 
These are especially the lowest notes, and which he 
appears to attribute to a partially exhausted state of the 
tympanum, in consequence of which the external air 
presses forcibly upon the membrane, and its vibration is 
only to be procured by sound more or less sharp. This 
constitutes a species of partial deafness, in which the 
person hears the voice when raised to a higher pitch, 
though it may not be louder than before. 

Different persons have also various limits to their ex- 
tent of hearing; thus many very acute sounds, as the 
chirping of some insects, though generally producing an 
effect in persons with ordinary hearing, can never be per- 
ceived by others. 

This limitation in many instances may depend upon 
some deficiency in the organ itself, and frequently upon 



MALFORMATIONS OF THE EAR. m 

a lessened sensibility of the nerve ; yet in very many 
cases it must be attributed to an incapacity in the senso- 
rium to perceive an impression so slightly made. 

By frequent use and great attention to musical sounds, 
without doubt, the organ, and especially the small mus- 
cles and the acoustic nerve, may become more active 
in its functions ; but the condition, which has been termed 
" the good Ear for music," is to be referred to a superiority 
of that mental faculty which, readily perceiving the im- 
pression, is capable of associating and comparing the 
rapid notes, and forming a judgment of their harmony or 
discord. 



PART II. 



ON THE ABNORMAL CONDITION OF THE EAR. 

In considering the variations from the ordinary struc- 
ture, and healthy state of the Ear, it is purposed to treat 
first of the malformations which have been observed, 
with their treatment, to the slight extent that has been 
hitherto found capable of application ; and then to describe 
the diseases, properly so called, or the deviations from 
the healthy state of the organ, originally well-formed. 

MALFORMATIONS OF THE EAR. 

In consequence of the study of developmental ana- 
tomy, it has been ascertained that most of the malforma- 
tions to which the different organs are liable, ought more 
strictly to be considered as deficient formations ; that the 
structures having proceeded to a certain extent, from 



212 MALFORMATIONS OP THE EAR. 

some cause, occasionally suspected, but much more fre- 
quently not, the organization ceases to extend, and the 
part remains partially formed, while the rest of the animal 
may be completed. The incompletion may affect an 
entire organ, or only a part of the apparatus, the rest 
being normal. Although this is the general mode in 
which malformations occur, it is very certain that organs, 
entire or in part, are occasionally improperly constructed ; 
and in many instances, that there is an exuberance of for- 
mation ; in both cases constituting what may more pro- 
perly be termed Lusus Naturce. 

In noticing the most frequent deviations in the forma- 
tion of the human Ear, it will be apparent that they do 
not differ from the general law, and that most of them 
must be viewed as deficiencies. And as different por- 
tions of the organ, at different periods of formation, bear 
an analogy more or less striking to similar parts in the 
lower animals, so it is easy to trace in their malformations 
a correspondence to the permanent structure of the infe- 
rior classes. Such being the real character of the so-called 
malformations, it will be advisable to premise their his- 
tory with a slight sketch of the formative process in the 
several parts of the auditory organ. 

The Auricle is first perceived about the middle of the 
second month of foetal existence ; when it presents a very 
small elongated triangular eminence, the base above, the 
apex below, and not separated from the skin of the face 
and head : it has a longitudinal depression, becoming 
narrower and deeper from above downwards. In a short 
time the posterior margin is elevated, and projects from 
the side of the head, eventually to form the Anti-helix. 
About the same time a transverse slit divides the anterior 
portion into an upper part, forming the commencement 
of the Helix, and a lower to be converted into the Tragus. 
Early in the third month the Anti-helix and Anti- tragus 
are developed. The Lobus is the last part which makes 
its appearance. During this formation the anti-helix is 
more apparent and projecting than the rest, in consequence 
of the tardy growth of the posterior edge into the helix. 
The entire auricle is particularly small in proportion to 
the size of the foetus. Its cartilage begins to be deposited 



AURICLE. 



113 



about the third month, and so slow is its progress that it 
is hardly completed at birth. 

The malformations of the auricle most frequently met 
with are : — 

1st. A deficiency of the Helix, usually of the posterior 
part, and sometimes its division from the lobus. It is not 
at all uncommon to see the helix so very small and flat, 
and so nearly concealed by the anti-helix, as hardly to 
deserve to be accounted as a distinct process. Such a 
limitation of its growth is sometimes the consequence of 
the pressure of the dress; which may, however, in gene- 
ral, be readily distinguished from original deficiency. 
The horizontal portion of the helix frequently extends 
backwards to the anti-helix, and being then very promi- 
nent completely divides the concha into an upper and 
lower depression. 

2d. An entire absence of the Lobus now and then oc- 
curs, resembling the natural condition of the early forma- 
tion. More frequently it happens that it is attached 
wholly or partially to the integument of the side of the 
head. And occasionally it has been found divided by a 
slit into an anterior and posterior portion. 

3d. The Tragus and Anti-tragus have been seen united 
more or less extensively, particularly at their lower borders, 
so as partially to close the opening of the meatus. They 
are also sometimes inverted towards the canal, producing 
the same effect. One or both of these bodies are occa- 
sionally divided into two portions. 

4th. The total absence of the auricle has been several 
times reported, by Meckel and others. Mr. S. Cooper, 
in his valuable dictionary, relates a case which he and 
many other surgeons saw, of a child entirely destitute of 
all appearance of external Ears, and with no vestiges of 
the meatus auditorii, these openings being completely 
covered by the common integuments ; the child, how- 
ever, could hear tolerably well. 

5th. An enormous enlargement of the outer Ear, may 
be enumerated as one of its malformations. An increased 
size is often the result of manipulation, or the dress 
stretching the part ; but it also occurs as an original con- 



114 



MALFORMATIONS OF THE EAR. 



formation. An unusual pendulous growth from the lobe 
or any other part, may be readily removed. 

Of these deviations, the absence of the auricle, and 
the closure of the opening will alone require surgical 
aid. The former appears to lessen, but slightly, the 
power of hearing, and the deficiency can only be sup- 
plied by an artificial Ear, as a cornet of metal, resem- 
bling in shape the auricle. And probably even this aid 
may not be required, as in proportion to the loss of one 
part of an organ, the rest, if healthy, has its capabilities 
augmented by increased exercise. The overlapping of 
the tragus and antitragus, if prejudicial to hearing, may 
be readily removed by the knife ; or if it be of small ex- 
tent, dilatation by the gentle pressure of a tube or a tent 
may be sufficient. 

The Meatus Auditorius Externus, the rudiment of 
which is also evinced about the second month, is entirely 
cartilaginous for some time after birth, and during foetal 
life, like the auricle, is especially narrow : it is formed 
from deposits in several points. At this period the car- 
tilage is attached to the margin of the petrous bone, im- 
mediately supporting the membrane of the tympanum. 
The osseous portion is a subsequent development of 
the processus auditivus, beyond the attachment of the 
membrane. As in the foetus, the membrane of the tym- 
panum is much more oblique than afterwards, the reflec- 
tion of the skin is proportionally much more extensive 
along the inferior than the superior surface of the mea- 
tus : in fact, it can hardly be said to exist above, but is 
particularly extensive, and folded below : it is generally 
also thicker and softer than in the adult. 

From this mode of formation, it must be anticipated, 
that the most frequent variations will be — 

1st. A very narrow canal ; indeed, its diameter is ob- 
served to vary from the ordinary size to complete oblitera- 
tion of the tube. The meatus of different individuals, all 
considered normal, vary in size and depth ; a merely con- 
tracted canal, and even when of undue length, not inter- 
fering with audition. Contraction to such an extent as 
not to admit a probe, must, however, importantly impair 



AUDITORY CANAL. 



115 



the function, as in a case related by Leschevin ; and if 
the canal should be completely closed, deafness must be 
the result. 

2d. A closure of the opening of the meatus by the 
integument stretched across it, and attached to its margin, 
resembling an imperforated anus. A similar imperfora- 
tion is described as occurring in any part of the canal, 
either by a portion of the lining membrane ; or, what is 
of much greater consequence, by a contraction in that 
particular part of the cartilage ; or even by an undue 
ossification of the bony portion of the tube. 

3d. Some few cases are recorded of a total absence of the 
meatus; as that related by Mr. Cooper. Of the few ex- 
amples of this kind, there has been in the greater number 
a deficiency of the whole organ, the want of the outer 
Ear being only a part of the general non-development. 

4th. The writer occasionally examines the meatus of a 
girl, (who has been some time deaf in the opposite ear,) 
which is unusually short and large, with a membrane 
corresponding in size ; she declares that hearing is per- 
fect in that ear, though, from the attention with which 
she listens to the voice, the contrary might be inferred. 
Such a condition has been alluded to by authors, and by 
Itard in particular, as a malformation ; and an extreme 
case of the kind might doubtless be so considered. The 
defect is only to be alleviated by the patient wearing a 
conical tube; and it maybe advantageous to have it 
slightly curved, something resembling the obliquity of 
the meatus. 

5th. Cases are occasionally occurring, in which the 
meatus at birth is completely rilled with the slimy caseous 
matter, which often covers the general surface of the in- 
fant, and which may be either deposited from the liquor 
amnii, or it may be a defensive secretion of the sebaceous 
follicles ; if this matter be allowed to remain, the deaf- 
ness which was at first undiscovered, may become per- 
manent, from the inactivity of the organ, and extreme 
hardness and fixity of the matter in the meatus. As this 
cause has been known to produce congenital cophosis, it 
behoves the practitioner carefully to examine the audi- 



llg MALFORMATIONS OF THE EAR. 

tory canal in all cases of birth, the matter being most 
easily removed while it continues moist. 

The surgical means to be employed in such states are 
very apparent. The introduction of tents, or silver tubes, 
gradually enlarged to the normal size of the meatus, will 
generally succeed in distending the canal ; as in most in- 
stances there exists rather a malarrangement of the carti- 
laginous fibres than an absolute deficiency. If this effect 
cannot be accomplished without danger of producing too 
much excitement, the patient must be satisfied with what 
aid acoustic instruments can afford him. 

In the more important instance of obliteration of the 
canal, either throughout its entire length, or in part, if 
the Surgeon has reason to expect that the organ is normal 
from the membrana tympani inwards, he doubtless will 
be justified in the attempt to form an artificial opening. 
This may be effected by the gradual introduction of a 
very small trocar, or by division with a very narrow knife, 
as nearly as possible in the natural oblique direction of 
the canal ; and afterwards maintaining and increasing the 
diameter by tents or tubes. In the unhappy cases where 
there is good reason to suspect that the malformation ex- 
tends to the internal organ : or where the obstruction is 
resisting and solid, and particularly if it be osseous ; the 
patient must be left to his fate, and if it occur on both 
sides, is incurably deaf; for the idea that, in such a case, 
it is possible he may ever hear through the Eustachian 
tube, if it should exist, is quite puerile. A tolerably good 
opinion may be formed, though certainly not a perfect 
one, of the capability of the labyrinth to be influenced by 
sound in cases of closure of the meatus, by exciting vi- 
brations in the cranium or in the facial bones, through 
the means of a watch, or of a wire thrown into a state of 
oscillation, brought into contact with the head or face. 
And much information may be obtained as to the condi- 
tion of the cavity of the tympanum by sounding through 
the Eustachian tube, 

A fold of skin across the opening, or of the lining mem- 
brane in any part of the tube, may be readily rectified by 
division with the lancet or narrow knife, or by perfora- 
tion with a trocar, if the passage be perfect behind it. 



OSSICULA. nj 

The Middle Ear, in its development, is well worthy 
the physiologist's study, as the greater number of the 
malformations of its component parts are the foetal con- 
ditions permanently retained ; and at different periods 
the analogies to the structures in the lower animals are 
more or less prominent. 

The Tympanum appears to be originally formed in 
connexion with the temporary branchial arches; Rolando, 
a very high authority, regards it as a pushing out of the 
mucous membrane of the Pharynx : but then he knew 
nothing of the branchige of mammalia. 

The cavity is proportionately smaller and narrower 
in the commencement of foetal life than at subsequent 
periods ; a state which corresponds to the smal] size of 
the mastoid-process, and the non-development of its cells. 
It is remarkable that the cavity is filled with a thickish 
gelatiniform matter, which occasionally remains after 
birth. The Eustachian tube is very short and broad, 
and opens almost immediately into the fauces, correspond- 
ing to the permanent condition in the amphibia. At 
the middle period of foetal life, the cartilaginous portion 
is membranous ; and at birth the osseous portion is still 
incomplete. The outer margin of the tympanum, and 
the membrane attached to it are large, not only in pro- 
portion to the outer Ear and the head, but also to the 
whole body ; and the younger the foetus the more strik- 
ing is this peculiarity. The membrane is also much 
nearer the surface, in consequence of the deficiency of 
the osseous part of the meatus ; and as the membrane is 
now much more oblique than in after-life, even approach- 
ing the horizontal position, so its upper margin is nearer 
to the opening of the meatus, which temporary arrange- 
ment somewhat resembles the permanent condition of 
this part in the reptiles. 

The Ossicula Auditus are remarkable for the early 
completion of their ossification, being indeed the first 
bones perfected in the body. Even at the beginning of 
the third month they may be distinguished, — as yet, how- 
ever, altogether cartilaginous; at the fourth month the 
malleus is three lines in length, while the trunk of the 
foetus being four inches, its proportion to the body is as 

15 



118 



MALFORMATIONS OF THE EAR. 



one to sixteen, whereas, in the adult, according to Meckel, 
it has a proportion of one to ninety. These little bones 
are as large at birth as in after life. It appears, from the 
observations of Meckel and the subsequent researches of 
Valentin, both of which differ in certain points from those 
of some other anatomists, that the ossification of the mal- 
leus and incus has proceeded to some extent while the 
stapes remains cartilaginous. The process certainly be- 
gins in the long crus of the incus, which becomes ossified 
earlier than the posterior. Its commencement in the 
stapes has been variously stated ; by some it is regarded 
as beginning at the head, and extending along the crura to 
the base, whereas Meckel has never seen it to commence 
at the head, but sometimes at the lower part of the poste- 
rior crus, sometimes at the base. In the malleus ossifi- 
cation appears to begin in the head. 

It is more interesting, however, to notice the changes 
which take place in the bones during their development. 
The incus hardly undergoes any alteration, unless, as 
described by Huschke, and confirmed by Valentin, its pos- 
terior crus is, in the very early period, connected with 
the os hyoides, and perhaps also with the styloid process, 
in a manner similar to the union of the malleus with 
Meckel's process. In the commencement the Stapes is 
not divided into two crura; it is a little solid bone, re- 
sembling that of the cetacea, and the inner portion of the 
columella of reptiles ; the opening between the processes 
and the base is gradually formed, being at first merely a 
depression, and remaining proportionally narrow for some 
time. The malleus is remarkable above all the other 
bones of the body by the changes consequent upon its 
development. In the early period, according to Meckel, 
it possesses " a straight cartilaginous apophysis, of the 
form of an elongated cane, and which is both very long 
and thick in proportion to the rest of the bone. This 
apophysis proceeds from the anterior part of the head of 
the bone, passes out of the cavity of the tympanum, be- 
tween the petrous portion and the margin for the mem- 
brane, and applying itself directly to the inner surface of 
the lower jaw, it extends to the anterior extremity of that 
bone, where the process sometimes, and perhaps always, 



OSSICULA. 



119 



unites with the corresponding one of the opposite side. 
This cartilage is never ossified, although at this period it 
forms the great mass of the bone ; and it disappears at 
the eighth month. The processus gracilis, to a certain 
extent, corresponds in situation to this process ; but as 
both are perceived at the same time in the foetus, and the 
cartilage being above the process, they are very distinct 
from each other. This cartilage, (which is termed, after 
its first describer, ' Meckel's process,') is very remarka- 
ble in fishes ; reptiles and birds possess a similar appen- 
dage, which extends from the posterior portion of the 
lower jaw to the anterior. In these animals it lies upon 
a little bone situated on the inner surface of the posterior 
piece of the inferior maxilla, and it is considered as a 
rudiment of a malleus." This temporary apophysis has 
doubtless led GeofFroy Saint Hilaire to describe the oper- 
cula of fishes as rudimentary ossicula auditus, as they 
hold a somewhat similar position ; and from the investi- 
gations of the German anatomists, it seems nearly proved 
that it is in the same situation during a short period of 
foetal existence, forming a part of the temporary bran- 
chiae. 

The malformations of the tympanum which have been 
recorded are not numerous, but of the utmost importance, 
as most of them are attended with deafness, and the cause 
is generally not to be removed. 

1. The cavity has been found much smaller than usual, 
retaining its early foetal character. It may be conceived 
that this condition, provided the appendages were nor- 
mal, might not give rise to deafness, though it w r ould be 
expected to diminish materially the power of hearing. 

2. Itard and others have described the outer wall as 
being ossified, in fact, that the bony plate has occupied 
the place of the membrana tympani. It is evident that 
such an unhappy formation must produce incurable 
deafness. 

3. The opposite condition of inordinate amplitude of 
the cavity is also reported to have been seen, of which 
cophosis was the consequence. 

4. More frequently occurring variations in conforma- 
tion than the above are to be met with in the ossicula, 



12Q MALFORMATIONS OF THE EAR. 

They have been found too small for the performance of 
their proper function by Bernard. Meckel states them 
to be sometimes of extraordinary dimensions, retaining 
the relative large size of the foetal period. They more 
commonly vary as to their shape, approaching more or 
less that of other animals. The Malleus has been seen 
abnormally long ; and again too short ; or with its pro- 
cesses unusually large. The Incus has also been found 
too long, or too narrow ; its long cms has been seen 
arched, and its short crus deficient. But the Stapes is 
most frequently recorded as malformed, probably partly 
in consequence of anatomists having directed their atten- 
tion to that bone rather than to the others, but especially 
no doubt from the mode of its formation tending to pro- 
duce more frequent varieties. Comparetti found, in a 
man, both stapedes, not only very small, but each com- 
posed of a single crus, with a very small base closing an 
equally small fenestra ovalis. Rudolphi and Lsesuke 
have described, and the former figured, a stapes with one 
crus communicating with the base, the other projecting 
out, forming with it an obtuse angle. The celebrated 
Tiedemann found in a new-born infant a stapes without 
branches or aperture; it resembled a little pyramid 
slightly depressed in the centre, and was in the "usual 
manner attached to the incus. The same acute anato- 
mist has seen this bone in an adult with its two crura 
united by a bony layer, producing a slight depression, 
but no opening between them. And Cruveilhier met 
with a stapes extremely small, and another in which the 
two cura were united. 

These variations bear strong analogies to the natural 
conditions at some period of the development; which 
fact is particularly to be recognized in the stapes. It 
may readily be comprehended how most of such varieties 
would be of little consequence to the function ; and that 
others, — as the incus, not being steadied by its short 
crus, — or the malleus too large, or its processes too long 
for perfect vibration, — would occasion difficulty of hear- 
ing ; and again, that the stapes being extremely small, 
or all the ossicula either being inordinate in size, or too 
diminutive, may be causes of incurable deafness. 



TYMPANUM. 



121 



The bones of the tympanum have been found ossified 
together, and the stapes to the fenestra ovalis ; such a 
circumstance will rather be caused by inflammation oc- 
curring after birth, or by excessive development during 
their growth, than by a vicious conformation ; the former 
condition is not necessarily attended by cophosis. 

It is not common to find the bones deficient ; a case is 
however reported in the Dictionnaire des Sciences Medi- 
cates, in which ail the ossicula were wanting ; and Mer- 
sanni found the incus absent, which produced deafness ; 
whilst, on the contrary, Galdani reports a case of deficient 
malleus and incus, from which but little inconvenience 
arose. 

It is very rare to find supernumerary bones ; when they 
have existed they have been very small, and placed be- 
tween the malleus and incus ; and one has been seen upon 
the neck of the stapes. 

5. In a case of congenital deafness, the tympanum has 
been found filled with a softish white matter, something 
resembling inspissated albumen, and supposed to be se- 
creted from the mucous membrane, and too thick to escape 
by the Eustachian tube. The cavity has been occupied 
likewise by a scrofulous deposit, occurring during its de- 
velopment. Mr. Cock in dissecting the Ears of five chil- 
dren who had died in the Deaf and Dumb Asylum, found 
in one the tympanum, together with the mastoid cells, 
completely filled with the thick cheesy deposit of scrofula, 
whilst a similar affection pervaded the whole cancellated 
structure of the petrous bone. The connections of the 
ossicula auditus were destroyed, but the bones themselves 
remained entire. Mr. Cock does not suppose that this 
deposit could have had any connection with the congeni- 
tal defect in the organ of hearing, as he imagines, it ex- 
isted but a short time previous to death. 

6. Congenital obliteration of the Eustachian tube, 
which is so essential an appendage to the tympanum, 
must be esteemed as an important malformation of the 
middle Ear. The Writer has neither heard of, nor read 
many reported cases of this nature ; yet, is it probable 
that some instances of congenital Dyseccea, having for its 
unfortunate concomitant dumbness, may depend upon the 



^22 MALFORMATIONS OF THE EAR. 

tube being originally closed, either in the cartilaginous 
or osseous portion ; or so much smaller than its natural 
diameter, as to transmit a volume of air insufficient for the 
necessary purposes. Sir A. Cooper, in the Philosophical 
Transactions, has mentioned the case of " Mr. John Round, 
seventeen years of age, who was deaf from birth to a de- 
gree to incapacitate him from engaging in business. He 
had an imperfect state of the fauces which rendered him 
incapable of blowing his nose ; the Eustachian tubes had 
no openings into the throat, he could not therefore force 
air from the mouth into the Ears. The auditory nerves 
were perfect, for he distinctly heard the watch, placed 
between the teeth, or against the bones of the head, and 
never had a buzzing noise in the Ears. The operation 
of puncturing the membrane of the tympanum was had 
recourse to, when a new world was immediately opened 
to him ; the confusion produced by the number of sounds 
nearly overpowered him : finding hearing was restored on 
one side, he wished to have it performed on the other, 
which w T as done with the same happy results. Two 
months after he wrote that he had no relapse, and his 
hearing was perfect." 

Unfortunately, however, it is rare that surgery can 
afford relief in these abnormal formations. The very ex- 
istence of the deafness in many instances is not discovered 
until the acoustic nerve has to a great, and sometimes to 
an irreparable degree lost its sensibility, or more cor- 
rectly its impressibility, and often when the cqphosis is 
suspected or detected, it is frequently attributed to the 
mental incapacity which accompanies it, but which is 
often its consequence, so that the examination of the or- 
gan is too long delayed for the useful application of reme- 
dies. The difficulty, and in the infant the impossibility, 
of discovering the malformation of the tympanum, places 
surgery at the greatest disadvantage ; and when a non- 
impressible condition of the nerve, or a malformation of 
the labyrinth co-exists, it becomes quite impossible to as- 
certain any unnatural structure, which is not evidenced 
to the Surgeon's sight or touch : this circumstance is, 
however, of the less importance, as the case is beyond the 
reach of remedial art. When, however, as in the case 



TYMPANUM. 



123 



related by Sir A. Cooper, the labyrinth, with its nerve is 
properly constructed and performing its healthy function, 
and the patient of an age capable of comprehension, and 
with hearing and speech sufficient to receive and to com- 
municate the ideas necessary to the inquiry, a correct 
diagnosis may frequently be formed. 

An examination by the meatus will teach the condition 
of the mernbrana tympani; and if it be ossified, although 
the internal Ear may receive the impression communi- 
cated by the bones of the head, and transmit it to the 
brain ; yet, the Dysecoea will be incurable, unless indeed, 
having assured himself of the perfection of the Eusta- 
chian tube, and hoping that the tympanic cavity is well 
formed, the Surgeon shall be bold enough to break away 
the ossified membrane, separating with it of course the 
malleus, and in all probability also the incus, and trusting 
that the stapes may remain in situ. Should such an 
operation be thus happily performed, and the consequent 
inflammation moderate, it is possible that an useful in- 
crease of hearing might be obtained. But the safe per- 
foration of the osseous structure would be nearly imprac- 
ticable, and the danger of destructive inflammation so 
great as to render the operation inadvisable. No Surgeon 
would feel himself justified in entertaining a momentary 
idea of such a proceeding, if one Ear were normal, and 
performing its functions correctly. 

The natural state of the membrane, and the perform- 
ance by the labyrinth of its function, will lead the sur- 
geon to examine the Eustachian tube ; and if air be not 
admitted to the tympanum during a forcible expiration 
with the noise and mouth closed, and upon the most care- 
ful sounding he finds the canal imperforate, he may in 
some rare cases overcome the obstruction in a manner to 
be noticed further on ; or, if he should discover that it is 
closed against all dilatation, Sir A. Cooper's operation is 
the only resource, and the sooner after the true state of 
the part is ascertained, the mernbrana tympani is punc- 
tured, the more probable will be a beneficial result. The 
impossibility of correctly ascertaining the condition of 
the Eustachian tube without direct exploration, must be 
manifest, and this is more particularly to be observed 



124 MALFORMATIONS OF THE EAR. 

in cases of deaf-dumbness. The Author has lately cathe- 
terized the tubes of a deaf-dumb young woman, and 
found them normal, readily admitting the injection of air 
into the tympani; yet during her childhood, one of the 
most scientific and justly celebrated surgeons pronounced 
her deafness to arise from an obliterated state of these 
canals. 

The presence of caseous or scrofulous matter in the 
tympanum, may be suspected, when, in addition to the 
action of the internal Ear, and the healthy state of the 
membrane, the Eustachian tube readily admits a sound 
or catheter, but does not transmit air; and a stylette or 
catgut sound introduced into the cavity, is besmeared with 
a whitish material. In such a case, the attempt, fre- 
quently repeated, to wash out the cavity with bland fluids, 
injected through the Eustachian tube, might be attended 
with success, provided the abnormal deposit is confined 
to the tympanum. 

The unnatural enlargement or diminution in the size 
of the cavity, and the variation in the structure or num- 
ber of the ossicula, will be altogether irremediable. 

The Labyrinth, which is developed earlier than the 
tympanum, and quite independently of that cavity, pre- 
sents circumstances of considerable interest in its forma- 
tion. The membranous canals are formed some time 
prior to the osseous : even at the third month, according 
to J. F. Meckel, they are completely developed, surround- 
ed by a structure entirely cartilaginous, and which is de- 
stined afterwards to become ossified. The membranes 
are at first double, one contained within the other, but 
without any continuity ; and together they are thicker 
and more resisting than at subsequent periods. The in- 
ternal membrane is whitish, transparent, thinner, but 
stronger and more elastic than the external ; which latter 
does not appear to be attached to the cartilage, though 
eventually it adheres to the bone which is developed in 
the cartilage. The external membrane — the inner face 
of which is smooth, and the outer roughish, — gradually 
becomes thinner, and having secreted the bony walls, at 
last disappears, so that at the seventh month no trace of 
it is left. The internal becomes in proportion narrower 



LABYRINTH. 



125 



and stronger, and soon after its formation is attached to 
the surrounding cartilage, from which it subsequently 
separates to constitute the membranous labyrinth. Mec- 
kel has not been able to ascertain, if at any early period 
of formation the membranous labyrinth is unconnected 
and loose in the cavity of the cranium ; or whether its 
structure is more simple than it is seen at the third month, 
when it is surrounded by a cartilaginous mass, and is as 
complicated as at more advanced periods. He has re- 
marked that, like the enveloping cartilage, it projects at 
first more inwards, and is more elevated, than afterwards, 
which depends upon the increasing size of the brain. 
Valentin however describes the labyrinth, in its earliest 
periods, as a simple longitudinal sac, being somewhat 
uneven on its interior ; which may be considered as the 
rudimentary vestibule; and that this is so completely 
insulated from the surrounding textures, that it may be 
readily drawn out, and that too when the cochlea and 
semicircular canals are somewhat advanced in their for- 
mation. Even previously to this period, Huschke and 
Valentin have recognised the sac, afterwards to become 
the labyrinth, presenting the appearance of a little gland ; 
they unhesitatingly affirm that the sacs of the right and 
left ears, previously to the origin of the nerves, commu- 
nicate together. 

At the fourth month, the membranous cochlea is as 
complicated as in the adult, while even later, it is sur- 
rounded only by a thick membrane, which forms a part 
of the common membranous labyrinth. Meckel, who 
has so accurately investigated the developmental anatomy 
of the Ear, has not ascertained what form, the cochlea 
presents previously to the fourth month of foetal life ; it 
however appears, from the investigations of others, that 
it at first assumes the shape of a little sac prolonged from 
the vestibule, which is partially divided by a straight 
septum, resembling very nearly the simple cochlea of the 
bird and of the reptile. The investigations of Valentin 
lead him to describe the commencement of the develop- 
ment of the cochlea as preceding that of the semicircular 
canals. The latter are elongations of the vestibular sac, 

16 



226 MALFORMATIONS OF THE EAR, 

and he has ascertained that the posterior is first formed, 
then the superior, and lastly, the external. It is inter- 
esting to notice the very large calibre of the canals at 
their early period ; they become gradually contracted as 
their development proceeds, leaving only their ampullae 
of the original size. The fenestra rotunda and its mem- 
brane are, at Iheir commencement, placed more exter- 
nally and parallel to the membrane of the tympanum; 
assuming their permanent position as the bone is depo- 
sited. 

The bony labyrinth is formed independently of the 
petrous portion of the temporal bone, which is ossified 
in the usual way, through the medium of cartilage ; the 
circumference of the fenestra rotunda is first formed, 
about the third month, which is somewhat remarkable, 
as it thus corresponds to the outer margin of the tym- 
panum. At the same period, an osseous point, altogether 
distinct from the petrous bone, commences at the external 
margin of the vertical canal ; and another in the centre 
of the- posterior canal : these nuclei extend to form the 
canals, and likewise downwards to construct the floor of 
the labyrinth. The superior canal, according to Meckel, 
but from which opinion Valentin differs, is the first com- 
pleted, when from its inner surface the ossification extend- 
ing, surrounds the meatus auditorius internus, internal 
to the portio petrosa ; it also now forms the base of the 
cochlea. The horizontal semicircular canal begins its 
ossification not till the fifth month, when the bony deposit 
extends from the vertical, downwards, outwards, and 
backwards, around its membrane. The interior of the 
cochlea is formed entirely from the osseous labyrinth; 
the petrous portion only occupping the narrow external 
interstices between the spires. The ossification of the 
cochlea commences from the upper edge of the fenestra 
rotunda, and extends, upon the external surface, to the 
apex, then crossing its centre, so as to form an incomplete 
division into an internal and external cavity. The outer 
surface of the cochlea is at this time smooth, and like the 
membranous portion it also bears a considerable resem- 
blance to the similar structure in the bird and reptile. As 
the cochlea enlarges from without inwards, this septum 



LABYRINTH. 



127 



becomes narrower, and little projections are formed upon 
it, eventually to constitute the spiral division. 

In the early period, the osseous labyrinth is quite 
separated from the petrous portion by which it is sur- 
rounded ; the outer surface of the labyrinth being smooth, 
while the opposed bone is roughish ; they are soon united 
together, yet even in infancy, the line of demarcation 
may be distinguished, and the petrous bone be neatly re- 
moved, loaving the surface of the labyrinth polished ; in 
the course of some months they become inseparable. 
This line of demarcation, though perfect throughout the 
labyrinth, is best marked over the cochlea. 

As the osseous labyrinth is formed independently of the 
petrous bone, an excellent opportunity of dissecting the 
internal Ear is afforded, previously to their union ; and 
as the external of the two membranes disappears, as the 
ossification is progressing, it is more than probable, that 
having secreted the bone by its outer surface, it is lost as 
a distinct membrane, by becoming the internal lining of 
the osseous labyrinth. Probably the same membrane 
previously forms the membranous canals. Thus, then, 
the formation of the labyrinth nearly corresponds to that 
of the teeth. Ribesjias described the perilymph as being 
reddish, and as exactly filling the canals, during the foetal 
period; whilst during the earliest childhood it becomes 
clear and limpid, and its quantity lessened in proportion 
as the Ear becomes sensible to sound. Valentin on the 
contrary declares, that the fluid is clear and transparent, 
from its first formation. The two fluids are secreted by 
the respective membranes which contain them. 

Although the deafness which arises in consequence of 
malformation of the labyrinth is irremediable, and with 
our present extent of knowledge the variations in forma- 
tion can only be guessed at ; yet so pitiable is the insu- 
lated condition of the deaf and dumb, that it becomes the 
surgeon's duty to chronicle the abnormal constructions 
which have occasionally been discovered, as a possibility 
may exist, that hereafter the precise malformation may 
be once in many instances ascertained, and perhaps to a 
degree remedied. 

1. Rcederer and Meckel have described a development 



128 MALFORMATIONS OF THE EAR. 

of the labyrinth so imperfect, that one single cavity only 
existed, — undivided into vestibule, semicircular canals, 
and cochlea, and closed at its outer border so as not to 
communicate with the tympanum. Such a form bears 
an analogy to the simple Ear of the Crustacea, and may 
perhaps be the normal condition at some very early period 
in the human foetus. 

2. The Cochlea has resembled that of some lower ani- 
mals, by forming only one turn and a half, as detected 
by Mondini, and it has been seen to form merely a cul- 
de-sac, without any spiral, corresponding to the tempo- 
rary condition in the foetus, and to the permanent state 
in birds and reptiles. Since the cases mentioned below 
were published, Mr. Cock, in the further dissections of 
children who have died in the Asylum for the Deaf and 
Dumb, has met with several cases of malformed cochleae ; 
in one a simple cul-de-sac was formed, communicating 
very largely with the vestibule, resembling a conical dis- 
tension of that cavity ; in another the cochlea was alto- 
gether deficient, its situation being occupied by bone so 
dense and hard as to resist the saw. In two there were 
slight attempts to form the spiral septa and the axes, these 
portions being quite rudimentary. In one of these in- 
stances the semicircular canals were also imperfect. Mr. 
Cock has published a detailed account of these interest- 
ing dissections, in the seventh number of Guy's Hospital 
Reports, which is accompanied by diagrams illustrative 
of the malformations, for copies of which see Plate XII., 
figs, 13, 14, 15. These imperfect developments of the 
cochlea have been supposed to be the causes of cophosis, 
inasmuch as they were met with in the deaf, but if the 
other parts of the Ear were healthy, it is difficult to un- 
derstand how these defects alone could give rise to such 
an extensive effect. 

3. Mondini has also related an instance of an imperfect 
ossification of the bony labyrinth, in consequence of 
which the membranous labyrinth was partly exposed. 

4. In a very interesting paper in the nineteenth volume 
of the Medico-Chirurgical Transactions, Mr. Cock has 
described, and illustrated by diagrams, two examples of 
partial deficiency of the semicircular canals. " The 



TZa^te /2 



Fxg.1 




Fig 2. 



Fig 3 





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Fig. d. 





"Vfcj;: 



Fig 8'. 




Fig 9 




Fig 10. 



Fig. // 





Fig. /£ 




Fig. IS. 



Tig. /S 



Fig. 14 




LABYRINTH. 



129 



extremities of these tubes, opening into the vestibule, 
were perfect, but the central portions were impervious, 



PLATE XII. 

Fig. 1. — Membrana Tympani of Mr. G., of which only that 

part which is of a lighter colour remains. 
Fig. 2. — The Membrane lacerated by a blow. 
Fig. 3. — The Membrane lacerated in the attempt to extract a 

w. P in - 

Fig. 4. — The Membrane of a Medical Man, having a fungus 

projecting through it; — in this ear he is consider- 
ably deaf. 

Fig. 5. — The other Membrane of the same gentleman. 

Fig. 6. — One of the Membranes of Mr. P., whose case first sug- 
gested the idea of puncturing the Membrane. 

Fig. 7. — The appearance of the Membrane after the operation 
of puncturing. 

The above are copied from Sir A. Cooper's Plate in the Philosophical Transactions. 

Fig. 8. — Represents the Membrane of Miss J. R.'s left ear. 

Fig. 9. — The appearance of Miss M.'s ear, the Membrane being 
removed, — the Incus is plainly seen, with the Stapes 
in outline, the Malleus being lost. 

Fig. 10. — Represents the malformed semicircular canals of the 
first case, and right, ear of the second case described 
by Mr. Cock. 

Fig. 11. — The canals of the left ear in Mr. Cock's second case. 
The dotted lines denote the defective portions. 

Fig. 12. — Represents Mr. Thurnam's case of imperfect horizon- 
tal canal in the right ear. 

Fig. 13. — Malformed Cochlea, the Canals being deficient, a. The 
Vestibule ; b. The Cochlea ; c. The commencement 
of the Fallopian canal, laid open by the Section. 

Fig. 14. — Malformed Cochlea and Canals, a. Vestibule ; b. Ab- 
normal continuity between the vertical and oblique 
semicircular Canals ; c. Meatus auditorius internus; 
d. Irregular cavity representing the Cochlea, with a 
rudimentary lamina spiralis. 

Fig. 15. — Malformed Cochlea and Aqueduct, a. Vestibule; 
b. Vertical semicircular Canal ; c. Meatus audito- 
rius internus ; d. Irregular cavity representing the 
Cochlea ; e. Aquasductus Vestibuli, preternaturally 
large. 



130 MALFORMATIONS OF THE EAR. 

or rather did not exist at all: In the first case he had an 
opportunity of examining the Ear of one side only. The 
vertical and oblique semicircular canals were both im- 
pervious at their central points. In the second case both 
Ears were examined. On the right side, the middle por- 
tions of the oblique and vertical canals were wanting, the 
bone presenting the appearance of the first case. On 
the left side, the horizontal and vertical canals exhibited 
a similar imperfection. The scala tympani likewise was 
terminated, at its larger extremity, by a bony septum, 
which separated it from the tympanum, and occupied the 
situation of the membrane of the fenestra rotunda.' 7 
(Plate XII., figs. 10, 11.) 

The same volume contains the account by Mr. Thur- 
nam, of a dissection of a boy, aged thirteen years, con- 
genially deaf; the horizontal semicircular canal was 
imperfect on the right side, in about the outer third of 
its extent ; but what, perhaps, might be regarded as an 
abortive attempt at its formation existed (Plate XIL, 
fig. 12). He did not discover any trace of sacculus or 
utriculus vestibuli, nor of membranous semicircular 
canals. 

In the left Ear the osseous canals were perfect, but the 
membranous were very minute and gelatiniform, and 
there was no sacculus in the vestibule. 

5. Closure of the fenestra rotunda by ossification, must 
be considered as a most important malformation ; and if 
the views taken of the physiology of hearing in an earlier 
part of this essay be correct, such an irregularity of con- 
struction must, by preventing the undulations of the 
fluid, prove an invincible barrier to the function. It is 
unfortunate that in the second case quoted above from 
Mr. Cock, it is not stated to what degree the child was 
deaf; and if it heard at all, whether the function was 
confined to the right Ear ; as we should be led to infer 
that some impression might be made upon the nerve 
through the one perfect canal, cochlea and vestibule, 
where the membrane of the round opening was perfect, 
and that cophosis would be complete in the left organ the 
fenestra rotunda being closed by bone. 

Mr. Cock has had another opportunity furnished by 



LABYRINTH. 



131 



the same charity, of ascertaining the cause of congenital 
deafness ; in the case of this child " not a vestige was to 
be found of the fenestra rotunda on either side, the usual 
situation of the membrane being occupied by solid bone." 
" The temporal bones were exceeedingly large, though 
soft and spongy in texture. The cavities were more than 
usually capacious, and the Eustachian tubes presented a 
remarkable development, being three or four times larger 
than common. On one side, the aqueduct of the vesti- 
bule readily allowed the passage of a large bristle ; on the 
other side, the canal could not be traced through the 
bone, although its two extremities were more than usually 
expanded." 

Ribes has described a similar malformation of the fenes- 
tra rotunda. 

6. As by some physiologists the aqueducts of Cotun- 
nus are esteemed appendages to the labyrinth essential 
to hearing, the abnormal enlargement of that of the vesti- 
bule may here be alluded to as a malformation, although 
it may admit of a doubt if such a variation can produce 
an important defect of function. Allusion has been made 
to its imperfection in a case above noticed. Mr. Dalrym- 
ple is quoted by Mr. Cock, to have ascertained by dis- 
section of a case of congenital deafness, that " the Aquae- 
ductus Vestibuli was so large as to admit the passage of 
a small probe, whereas, in the natural state, a fine hair 
can with difficulty be introduced into the canal." He 
imagines this defect to become a cause of deafness, by 
allowing the fluid to recede so readily from the vestibule, 
that its undulations will not extend to the canals and 
cochlea. 

7. Several cases are recorded of an alteration in the 
contents of the membranous labyrinth. Sir A. Cooper, 
in the Philosophical Transactions, relates a case dissected 
by Mr. Cline, of a young man who had been deaf and 
dumb from birth, in which " all the parts were healthy 
and perfect, except the vestibule, cochlea, and semicir- 
cular canals, and these were filled with a substance of 
the consistence of cheese, instead of the fluid usually con- 
tained." Dr. Haighton met with a case in which the 



132 MALFORMATIONS OF THE EAR. 

vestibule was filled with caseous matter. Mr. Thurnam, 
and Mr. Cock coincides in the opinion, thinks it possible 
that these cases may have been deceptive, as the bone 
dust, produced by the saw, combining with the water of 
the labyrinth, presents a similar appearance : it can, how- 
ever, hardly be conceived that such acute observers of 
nature would run into this error ; and as such a deposit 
■undoubtedly has been found in the tympanum, as a con- 
genital defect, and as the effect produced was that which 
would be expected, it is much more probable that the 
variation existed as an original formation. Itard has de- 
scribed a calcareous body in the vestibule, as a mal- 
deposit producing deafness. It is possible that this ap- 
pearance may be the otolithe of Breschet, although we 
have doubted its existence in the human Ear. If it 
should occur as a malformation, it affords another exam- 
ple of the occasional approximation in peculiar structures 
of man to those of the lower animals. A deficiency in the 
aqua labyrinthi, leaving a dry and empty state of the 
canals, has been noticed by Pinel as a cause of loss of 
function. Such a deficiency of secretion, it appears, is 
not an uncommon cause of senile cophosis, though pro- 
bably not often occurring as a congenital condition. Over 
accumulation of fluid is also named as a probable preven- 
tive of its undulations. 

8. In this general enumeration of the different deviations 
from the normal formation, it is necessary to allude to the 
absence of the utriculus vestibuli, as noticed by Mr. 
Thurnam in the above case, though he does not state 
whether the fluid was likewise deficient, or whether it 
was contained in the vestibule in contact with the lining 
membrane of the bone, constituting a part of the peri- 
lymph. An absence of the fluid must be completely de- 
trimental to the function of hearing ; but it may be ques- 
tioned to what extent cophosis would be produced by the 
want of the membranous sac alone. 

9. Lastly, the total absence of the labyrinth ; — to such 
a deficiency Meckel has alluded as having been seen by 
Rcederer, accompanied by an absence of the rest of the 
organ ; in fact, the whole ear was wanting. The instance 



ACOUSTIC NERVE. ^33 

seen by Mr. S. Cooper could not have been an example 
of this most rare deficiency in development, as the child 
is reported to have heard tolerably well. 

Probably the most frequent cause of congenital deaf- 
ness is seated in the acoustic nerve, in some part of its 
course, origin, or distribution, or perhaps in its entire 
structure. The lost of audition has been generally attri- 
buted to some derangement in structure or inaction of the 
nerve ; and as upon very careful dissection no variation 
is often to be found corresponding to the loss of function, 
pathologists may be excused for attributing it to a faulty 
nerve, though in appearance it may be normal. The 
nerve, however, has presented vitiations in development : 
Haighton, Sylvius, Hoffman, and others have met with 
it less than half its customary size : Itard has seen exam- 
ples of such diminution, which he, however, considers 
rather as a consequence, than as the cause of the deaf- 
ness. The nerve has also been found harder than natu- 
ral, even more firm than the accompanying facial ; this 
deviation was noticed by Rosenthal. It has been ren- 
dered non-impressible or insensible by compression from 
a steatoma. Likewise it has been found completely dis- 
organized, the neurilema holding in its interstices a little 
fluid only ; such derangement is perhaps more frequently 
the result of long continued inactivity of the nerve, (as is 
frequently seen in the case of the optic nerve, in conse- 
quence of blindness,) than the cause of the deafness. 

In a treatise on the Ear it would be misplaced to de- 
scribe the malformations or deficiencies in the develop- 
ment of the brain, which must produce dyseccea, con- 
joined with a partial, or complete loss of the other func- 
tions of sense. 

The majority of instances in which the organs of hear- 
ing of the deaf and dumb have been examined, have not 
presented vitiations of form which would account for the 
loss of function. Of the five cases published by Mr. Cock, 
although they all furnished evident and well marked 
traces of scrofulous disease, yet two only presented mal- 
formations, which that excellent anatomist could consider 
as cognate, and as the cause of the deafness. Although 
the cause of congenital cophosis may remain concealed, 

17 



J 34 MALFORMATIONS OF THE EAR. 

it is unphilosophical to declare, with some aurists, that 
the affection does not result from defective formation, and 
that therefore it is fruitless ever to attempt its investiga- 
tion with the view of applying remedies ; it is now well 
understood that there exist minute changes in the anato- 
mical arrangement of particles which the investigator has 
not as yet the means of unfolding, but which may yet 
be incompatible with the performance of the function of 
the organ : this observation being peculiarly applicable 
to the nervous system, it may occur that some deficiency 
may exist in the tympanic plexus of nerves, sufficient to 
interfere with the mechanical operations of the organ, — 
or in the sensory nerve, capable of preventing its vital 
functions, — both of which may elude the most careful 
searching. Nevertheless, besides the great difficulty, nay 
impossibility, of fixing the seat of malformation, when it 
is out of view, or beyond exploration, it must be recollect- 
ed that as the imperfection of audition is often occasioned 
by a cause not to be detected even when the organ is laid 
open to our sight, so it may be expected that the greater 
number of cases of deaf-dumbness will remain incurable. 
As might be anticipated from what has preceded re- 
garding the malformations, the degree of deafness varies. 
In few instances is it at first quite complete ; but as the 
infant is incapable of the mental attention necessary to 
catch the slight influence conveyed to its immature mind, 
and as the sounds ordinarily falling upon its imperfect 
ear, are insufficient to produce an effect, the labyrinth, 
and the auditory nerve in particular, become less and less 
capable of being called into action ; and thus in a short 
time, perhaps even before the defect is recognized, the 
function is diminished almost to entire deafness. It be- 
comes, therefore, absolutely requisite that the very first 
indications of deficient audition should excite alarm, and 
consequently attention to its causes and treatment on the 
part of the parents and practitioner. If any remedy is ap- 
plicable, it must be used very early : examples are not 
wanting in which the original defect has been removed 
from the external ear or the tympanum, but the sense of 
hearing has been but partially restored, and that with dif- 
ficulty, in consequence of the long state of inactivity of 



DEAF-DUMBNESS. 



135 



the nerve ; and perhaps also of the portion of brain from 
which the nerve proceeds. 

The Author has lately witnessed an interesting exam- 
ple of this fact, in a sourd-muet eighteen years old, in 
whom the function is gradually improving, under the judi- 
cious use of the organ, although the malformation being 
seated in the labyrinth is irremovable : in this instance 
the sense is not quite so defective on one side as on the 
other, which catheterism of the Eustachian tubes proved 
to depend upon the normal condition of one and the con- 
tracted state of the other canal. 

Writers on acoustic surgery, and particularly Rosenthal 
and Itard, have arranged the degrees of deafness. The 
former author has adopted three divisions : — 1. Surditas, 
cophosis, or deafness, in which the faculty of hearing ar- 
ticulated sounds is completely annihilated. — 2. Dyse- 
coea, difficulty of hearing, in which the function is so 
diminished that articulated sounds cannot be heard with- 
out the aid of an apparatus. — 3. Paracousis, alteration, 
or diminution of hearing, in which audition is imperfect 
for want of precision. 

Under these heads are included, not only the imperfec- 
tions arising from congenital defects, but also those pro- 
duced by acquired disease ; and the different terms are 
often used synonymously to indicate defective hearing. 

The various degrees of deafness will throw but little 
light upon the malformations producing them, — as they 
will be materially influenced by the mental and corporeal 
condition of the child, and by the circumstances intellec- 
tual and physical which surround it; thus the idiot with 
a perfect organ of sense is deaf to an extent depending 
upon his mental incapacity. It is quite possible that 
some cases of deficient structure, which may be occa- 
sioned by innate want of productive power, may be saved 
from the unfortunate combination of strumous deposit or 
disease, by an early treatment of the strumous diathesis; 
and it is worthy of remark that most children, who are 
affected with this sad deprivation, are of the scrofulous 
habit. Again, in instances where the sense of hearing is 
possessed to a limited extent only, that extent may be 
increased by an early, assiduous, and careful use of the 



136 MALFORMATIONS OF THE EAK. 

organ. Much may, therefore, be occasionally accom- 
plished, by affectionate assiduity on the part of the 
parent, and intelligent direction on that of the prac- 
titioner. 

The cases in which it has been supposed that the deaf- 
dumb have been taught to speak, are probably of this 
description ; inarticulate sounds have been heard ; and in 
his endeavour to repeat them, the deaf mute has been 
taught, through the medium of his acute sense of 
touch, but particularly of sight, so to influence his organs 
of voice and of speech as to produce an articulation ; the 
examples of the vowels being uttered in this manner are 
numerous. But as his own simple articulations are no 
more communicated to his sensorium, than are the more 
complex ones of his teacher, — as he can cannot compre- 
hend the thought intended to be conveyed by the unheard 
articulation, — and as he cannot clothe his own ideas in 
articulate language, but merely utter sounds, such as 
may be produced by Wheatstone's tubes, — the deaf- 
dumb cannot be said ever yet to have been taught to 
speak ; the criticism, therefore, of Kramer upon the in- 
stances related by Deleau and Itard, though severe, may 
be considered as just. 

Mankind cannot be too grateful for the zealous and 
successful exertions of those humane philosophers, who 
have, to a very great extent, succeeded in teaching the 
deaf mute a language of signs, by which he can hold 
rapid communication with his fellow man ; which, added 
to the facility with which he may be taught to read and 
write, goes far to remove him from the deplorable state 
of insulation, which his defect must otherwise entail; and 
to place a condition of usefulness and independence 
within his reach. 

It is a curious circumstance that deaf-dumbness is 
much more frequent in males than in females, which is 
in violation of the ordinary law, that as the power of for- 
mation is weaker in the female foetus than in the male, 
so are the deficiencies more frequent. Mr. May, the 
Director of the Deaf and Dumb School, at Vienna, stated 
that the proportion of deaf boys to girls was as four 
to one. 



DEAF-DUMBNESS. J 37 

Congenital deafness does not appear to be hereditary, 
as most of the parents of deaf children have had no de- 
fect of their organs ; and it is a rare circumstance to meet 
a case of a deaf child who was the fruit of parents, either 
one or both similarly affected. On the other hand, several 
children of one family will be thus defective, without any 
known cause, while the others will be perfectly healthy. 
Kramer relates the singular instance of " a man and his 
wife, of the name of Hartness, both of them healthy, and 
having no hereditary predisposition to any disease of the 
Ear in their family on either side, who have five daughters 
and six sons ; the latter were all born deaf-dumb, whilst 
the daughters, without exception, heard perfectly well. 
The mother of these eleven children is not aware of any 
circumstance that distinguished her pregnancies from 
each other, though the children are so remarkably differ- 
ently endowed. She was always healthy and active. 
One of their children has married a deaf-dumb girl, but 
their marriage has been childless." A healthy couple, 
residing in the parish of Bishopsgate, with a large family, 
have two of their daughters deaf and dumb ; the eldest, 
about forty years of age, has married a sourd-mnet, and 
become the mother of several children, all of whom enjoy 
perfect audition ; the youngest, aged twenty-six, can hear 
a few sounds, and indistinctly utter a few words, which, 
however, appear to be simply vocalized. The roof of her 
mouth is very concave; the right membrana tympani 
is abnormally oblique and very transparent, the left is 
opaque, but natural in shape and size, — the Eustachian 
tubes are healthy, — it is probable that the diameter of the 
right tympanum is smaller than usual, and that mal- 
formation exists in both labyrinths. 



J 38 DISEASES OF THE EAR. 



PART III. 



ON THE DISEASES OF THE EAR. 

In its pathology the Ear does not differ from other 
structures. From this general conclusion, perhaps, may 
be excepted inspissation of wax in the meatus, the exact 
analogue of that secretion not being elsewhere met with. 
Inflammation, therefore, is the affection to which, for the 
most part, this organ is obnoxious ; and as this disease is 
modified in its progress, in its symptoms, and in its effects, 
by the structures which it attacks, — by the local predis- 
position of the organ affected, by the general consti- 
tution of the individual, — by the causes which may 
excite it, — by the external circumstances, or conditions 
which accompany it, — so have the affections of the Ear 
been arranged under various heads, nearly all of which 
may be reduced to inflammation and its consequences. 
As in all other organs, of which the seat of function is in 
an expanded nerve, the Ear is likewise subject to an 
anaesthetic affection, dependent on some hidden morbid 
condition, and occasionally on inflammation, either of the 
acoustic nerve, or of those parts of the brain in connec- 
tion with the organ. Again, in consequence of the 
vicinity of the Ear to the brain, it often participates in 
the diseases and accidents of that organ ; and the reverse 
is frequently observed of disease extending from the Ear 
to the brain or the skull. Lastly, the accidental intro- 
duction of foreign bodies into the meatus; the rupture 
by a blow or otherwise of the membrana tympani, 
have been esteemed peculiar to the Ear ; but perhaps 
hardly with justice, as nearly similar accidents are met 
with in the nasal and visual organs. 

It is purposed first to treat of inflammation of the Ear 



OTITIS. 



139 



in general ; secondly, of its effects upon the different divi- 
sions of the organ, with observations upon the accidents 
and operations to which each division may be subjected ; 
and lastly, of the nervous affections, which are supposed 
to be independent of inflammation. 



CHAPTER I 

OTITIS. 

Until within a few years, the facts connected with the 
Ear were so scattered, and the conclusions deduced so 
vague, the diseases were so little understood and so mal- 
arranged, that the term otitis was hardly employed. 
Otalgia, or Ear-ache, was more frequently used, that 
symptom being very evident, though the cause remained 
concealed. 

Otitis, which term should imply the general disease of 
the whole organ, is arranged under the two heads Acute 
and Chronic; the latter form or degree of inflammation 
frequently being termed Otorrhosa, in consequence of the 
discharge of matter from the meatus, which often accom- 
panies it. Inflammation may either be External or In- 
ternal; the former including the affection of the auricle 
and meatus auditorius ; the latter that of the tympanum 
and labyrinth. In treating Otitis Interna, authors have 
more particularly described inflammation of the tympa- 
num and its consequences : as from its structure and 
situation, the labyrinth when inflamed does not present 
those direct evidences which are recognised in the Mid- 
dle Ear. 

Section I. 

Acute Otitis, Otalgia, or Ear-ache, does not frequently 
attack the entire organ at the same time, nor from the 
same cause; but generally commencing in either the 



140 DISEASES OF THE EAR. 

external Ear, or the tympanum, it extends to the rest of 
the apparatus ; thus, if the cause be applied, as often is 
the case, to the auricle or the meatus, the inflammation 
in its progress may reach the membrane and the cavity 
of the tympanum, and pass on to its appendages, and 
even to the labyrinth ; if on the other hand the inflam- 
mation be excited in the tympanum, immediately, or 
through the medium of the Eustachian tube, it may 
spread inwards to the labyrinth, and outwards to the mea- 
tus. This circumstance evidently arises from the differ- 
ent degrees of exposure to the exciting causes to which 
the outer and inner divisions of the Ear are liable : but 
it is very possible that the same sudden variation of tem- 
perature may inflame at the same time the external mea- 
tus, and the lining membrane of the tympanum, and thus 
that general Otitis shall arise, but this is comparatively 
an unusual occurrence. 

The Causes of Otitis are similar to those producing 
phlegmasia in other organs, modified in their frequency 
by the predispositions of the structures. Among the 
most common may be enumerated cold, and especially if 
suddenly applied to the Ear, when its temperature is un- 
naturally raised ; this exciting cause directly affects the 
auricle, and particularly the meatus, and indirectly the 
tympanum, through the Eustachian tube, — a foreign 
body irritating the auditory canal ; and wax inspissated 
to extreme hardness may be considered as a foreign irri- 
tant, — wounds of various kinds, sometimes lacerating, or 
cutting the membrane, — the extension of inflammation 
from the surrounding parts, particularly of Erysipelas 
from the scalp, of Scarlatina, of Variola, of Rubeola, &c, 
to the outer Ear ; of Tonsillitis, or Syphilis, or any affec- 
tion of the fauces to the Eustachian tube, and onwards to 
the tympanum, — ofdisease of the brain, or its membranes 
to the labyrinth, — likewise irritating injections adminis- 
tered to the auditory canal. Galvanism and Electricity 
have been enumerated as exciting causes, when too freely 
used for the removal of deafness. Inflammation is de- 
scribed also to have arisen from metastasis in consequence 
of the sudden removal of ophthalmia, or of gonorrhoea; 
likewise to have been excited by a carious tooth. Otitis 



OTITIS EXTERNA. 



141 



occasionally arises during the progress, or towards the 
termination of general acute disease, as continued or ty- 
phoid fevers. The disease is occasionally seen to pass to 
the Ear from the neighbouring parts, and back again, 
forming an alternating vicarious affection ; it also alter- 
nates in children with cutaneous eruptions, and especially 
during dentition. Individuals of the scrofulous diathesis, 
of the syphilitic taint, or having irritable mucous mem- 
branes, and those who are the subjects of cutaneous erup- 
tions, are particularly predisposed to Otitis; but this pre- 
disposition is most remarkable in strumous children. 
The symptoms and consequences of Otitis vary accord- 
ing to the structure of the part inflamed, and as these va- 
riations are very great, authors are obliged, for the sake 
of perspicuity, to describe separately the diseases as they 
are locally situated ; and hence the division of inflamma- 
tion of the Ear into external and internal, is not only jus- 
tifiable but very useful. 



Section II. 

Otitis Externa. — Acute inflammation may commence 
simultaneously in the auricle and meatus,the same cause 
affecting both parts at the same time, or it may be confined 
to either portion ; but more frequently it extends from 
the one to the other, and generally from the auricle to the 
canal ; yet the limitation of the disease to the meatus is a 
very common occurrence. 

Any cause of inflammation being applied will excite 
the auricle into disease ; but it is more frequently af- 
fected with erysipelas, than with any other form of acute 
disorder. This part is peculiarized by the great readi- 
ness with which it becomes tumefied, and in erysipelas 
by the large size of the vesications which are formed 
upon it ; which circumstances are consequent upon the 
perfect organization of the skin and subcutaneous cellular 
tissue. 

In the first instance there is rather a sense of heat than 
actual pain ; but afterwards there is a burning and pain- 
ful sensation, which soon becomes almost intolerable ; of 

18 



142 



DISEASES OF THE EAK. 



course the redness is excessive, the skin being naturally 
so very well supplied with blood. From these circum- 
stances it arises, that one of the most distressing concomi- 
tants of erysipelas is the impossibility of the patient- 
changing his posture from his back, to lie upon his side, 
in consequence of the unbearable pressure upon the Ear. 
The tumefaction of the concha is often so great as to 
completely close the opening of the meatus, by which 
nearly complete deafness is occasioned, even when the 
inflammation does not, as it generally does, extend into 
the canal. The disease often leaves the part thickened 
and hardened, by adhesive matter effused into the cellu- 
lar membrane, or sometimes by a positive deposition in 
the fibro-cartilage. In the majority of cases the auricle 
is restored in time to its normal condition by the process 
of absorption, but occasionally the part continues ever 
afterwards indurated. An abscess is sometimes produced, 
which endangers an ulceration of the cartilage, and oc- 
casionally ulceration, to which the structure of the auri- 
cle is predisposed, even takes place without the formation 
of matter ; an opening is thus sometimes formed through 
the cartilage, which is exceedingly likely to become per- 
manent. Sloughing of the cartilage is also now and then 
a termination of its inflammation ; this effect is most 
common when the Ear has been frost-bitten, under which 
circumstance, the vital powers have been much reduced 
by the extreme cold, and are, therefore, incapable of 
bearing the consequent violent reaction. 

The auricle is also the subject of erythema, of small- 
pox, of measles, in short of all the inflammatory actions, 
either common or peculiar, which affect the cutaneous 
system ; these different diseases pass through their ordi- 
nary stages, and produce their usual effects, with modifi- 
cations arising from the predisposition occasioned by the 
structure above alluded to. 

The treatment must be conducted upon general prin- 
ciples ; when the inflammation is peculiar, the object of 
the surgeon will be so far to lessen its severity, during 
the necessary progress, as to diminish the probability of 
the affection extending to the meatus ; this desirable ob- 
ject, however, is often not to be obtained, and in many 



OTITIS EXTERNA. 



143 



cases the patient must feel grateful if the spreading of 
the disease has been confined to the canal. With the 
above view bloodletting from numerous punctures made 
by a lancet, is attended with much advantage in erysipe- 
las. When the inflammation is excited bv common 
causes, antiphlogistic means actively employed, will fre- 
quently be successful, not only in limiting its seat, but 
also in confining its termination to effusion of serum, 
which will in most instances become easily absorbed. 
Induration, suppuration, or sloughing, will require the 
same treatment as when taking place in other parts of 
the body ; but as the cartilage lost by disease is rarely 
reproduced, it becomes the more important to diminish 
the extent of the acute stage. When applying stimulants 
to an unhealthy ulcer, or to a sloughing state of the auri- 
cle, the surgeon should be careful that the excitement be 
not carried to too great an amount, lest the meatus may 
be also unduly influenced. 

Inflammation of the External Auditory Canal is usually 
ushered in by an uneasiness in the tube, as though a fo- 
reign body were there producing rather titillation than 
pain, and the patient frequently introduces his finger to 
remove the supposed irritant, but the contact of the fin- 
ger, and distension of the canal exciting considerable pain, 
he immediately desists. The uneasiness soon augments 
into an itching sensation ; and in a little while is followed 
by pain, at first slight, then gradually, but with varying 
rapidity, increased in intensity, sometimes to an amount 
almost intolerable, and even, in the severer cases, produc- 
ing delirium and distressing exclamations from the very 
agony. When the pain is so very great, it is more than 
probable, that Otalgia, properly so called, or Ear-ache, is 
excited in the tympanum, which may undoubtedly occur 
without inflammation, and which nervous excitement 
often precedes that of the vascular system. The pain, in 
severe cases, is often lancinating, described as shooting 
through the head and face, and down the neck, attended 
by a burning sensation, and feeling of distension in 
the tube. Audition is always diminished, and entirely 
suspended, when, the inflammation is intense ; yet, fre- 
quently, there is a whistling or humming noise, still fur- 
ther increasing the annoyance of the patient. The pain 



j 44 DISEASES OF THE EAR. 

is augmented by pressure, — by moving the auricle in 
order to examine the canal, — by the motions of the jaw 
in mastication, and even in speaking, — and by the con- 
tact of cold air, or of too great heat, though relief is afford- 
ed by a temperature moderately raised. 

Upon examination of the auditory canal at the very 
commencement of the uneasiness, the lining membrane 
is found dry, and it may present a slight blush of red ; 
soon afterwards, as the pain increases, the membrane of 
the canal becomes swollen and red, and often spongy, 
which changes ensue with great facility in consequence 
of the vascularity of its structure ; from this cause alone 
the tube may even for a time be obliterated. When the 
inflammation has existed for a time, varying from a few 
hours to a day or more, the lining membrane is generally 
more or less covered with minute pustules or vesications, 
which are at first red, and if filled with serum become 
transparent ; or if with pus, as in the higher degrees of 
inflammation, they assume a whitish colour. Sometimes 
these pustules are very small and numerous, at others 
they are larger and fewer in number, and they often oc- 
cupy the whole length of the canal. Occasionally the 
serum is absorbed, but much more frequently the pustules 
or vesicles burst and the fluid escapes, giving rise to a 
discharge from the meatus. The matter escaping is often 
muco-purulent, very fetid and abundant, and where the 
inflammation has been severe it is frequently tinged with 
blood. This morbid secretion, which for the most part 
is the product of the ceruminous glands, may continue 
for a fortnight or three weeks, occasionally changing its 
degree of consistence, one day resembling pus and another 
mucus ; at last it gradually thickens into a caseous mat- 
ter, as the increased action subsides, and is followed by a 
copious formation of wax. Itard has named the latter form 
of the disease External Catarrhal Otitis, and that in 
which pus is formed in little pustules External Purulent 
Otitis. 

The Otitis Externa much resembles inflammation of 
the other mucous membranes, the character of the matter 
secreted corresponding to the degree of inflammation ; 
the slighter extent will fill the canal with mucus, — a 
greater amount with pus, — and it is frequently pustu- 



OTITIS EXTERNA. 



145 



lar ; in infants, who are especially subject to this affec- 
tion during dentition, the inflammation furnishes a mem- 
briform layer of inspissated fibrin, resembling that so often 
separated in acute affections of the other mucous mem- 
branes. 

In Erysipelatous Otitis, the vesicles having burst, fre- 
quently degenerate into very troublesome ulcers, which 
continue to suppurate for a long time, accompanied with 
more or less deafness. 

As comparatively a rare circumstance, an abscess is oc- 
casionally formed in the cellular tissue of the tube, in con- 
sequence of inflammation of the lining membrane; it 
occurs generally in the cartilaginous portion, and project- 
ing into the canal frequently there discharges its pus by 
ulceration ; it sometimes softens and ulcerates through 
the cartilage, forming an opening behind the meatus, 
where it is partly concealed by the lobus, and through 
which the matter escapes ; this aperture occasionally be- 
comes fistulous. As must have been noticed by every 
practitioner, an abscess is much more frequently formed 
in the cellular membrane surrounding the exterior of the 
canal, between it and the mastoid process, which becomes 
excessively painful from its confined position, — occasions 
cophosis by its pressure on the tube, and very often by 
ulceration discharges its pus into the meatus, which is 
the more easily effected in consequence of the natural di- 
visions of the cartilage. The opening in the canal is 
usually readily seen, and gentle pressure behind the Ear 
will force the matter through it. Such an abscess, the 
Author has several times met with in children during 
their dentition, which without doubt is one of the causes 
of otorrhcea, properly so called. Yet if promptly treated 
the meatus may occasionally escape from being injured : 
a child who was teething was brought to the Author 
with a swelling behind and in the Ear, which presented 
an indistinct fluctuation, and by which great suffering 
was evidently occasioned; the meatus was completely 
closed. Poultices, &c, were applied, and on the follow- 
ing day the abscess was opened behind the canal, the 
pus was readily discharged, and the wound healing in a 
few days the tube gradually assumed its healthy dimen- 



I^q DISEASES OF THE EAR. 

sions. A collection of matter has also occurred in front 
of the meatus, but more rarely, and Andral has seen pus, 
secreted in the parotid gland, find its exit through the 
auditory canal. The author is indebted to an intelligent 
friend for the following history of a case which points 
out the great destruction in which the Ear may be in- 
volved from surrounding disease. 

" Mrs. B., set. 43. — In April, 1838, was first attacked 
with acute pain in and about the right Ear, and the same 
side of the face and head, for which an unsound tooth 
was extracted, and afterwards a sound one was drawn, 
still without relief, though much of the pain appeared 
referrible to these teeth. Poultices and fomentations 
with medicines, sometimes tonic, as for tic doloureux, 
sometimes of other kinds w r ere administered. She had 
during this first stage of the complaint occasional shiver- 
ings, and the hearing became very obtuse, — the pains 
were not constant, having exacerbation and remission, — 
the night, or the day also if she reclined, being much 
the worst, — the right eye began in two or three w r eeks 
to appear very weak, and the conjunctiva often became 
vascular, and the sight impaired ; as she became worse 
I saw her and brought her to London. From the 
seat and character of the pain, the slight discharge 
from the Ear, the deafness, the shivering, the extreme 
heat over the Ear, mastoid cells, and at the upper part of 
the sterno-cleido-rnastoid muscle extending forward to 
the angle of the jaw, I suspected abscess, but it was so 
deep, and in connection with such important parts that 
it could not be opened. This would again have been 
attempted, but that in a few hours a large gush of pure 
pus came from the Ear, and some time after their ap- 
peared to be a collection just below the mastoid process 
which I opened, matter escaped, and this I found had an 
imperfect connection with the meatus externus ; tempo- 
rary relief was always obtained by getting the matter 
from the Ear, which could be forced in no other way 
than by opening the jaw, which process, an exceedingly 
painful one, would as it were pump the matter out ; often, 
however, the accumulation of matter prevented the open- 
ing of the jaw, — the Ear was kept syringed with warm 



OTITIS EXTERNA. 



147 



water and opium ; poultices, and fomentations, were ap- 
plied. Oftentimes I dropped into the meatus almond oil 
with morphine : when the sac of the abscess became 
inflamed, which, occasionally happened, two or three 
leeches produced relief; aperients and some general means 
for giving tone to the system, were now with opiates the 
plan adopted ; once or twice I saw small portions of grit 
which to me seemed like the ossicula of the Ear broken 
up. About two months from the commencement, the 
pain in the face (right side) became combined with numb- 
ness, the features^ especially in smiling, were drawn to 
the left side, the muscles of the right side of the face, the 
orbicularis of the eye, &c, seemed to be losing their con- 
tractile power, — the eye became much w r eaker, - — the 
sight being at one time nearly lost, which was benefitted 
by the application of two small blisters, — the right side 
of the tongue became quite benumbed, and the taste of 
food was imperfect, — pain was also felt in all the teeth 
on this side. It must be observed, that at all times the 
pain extended over no more than the right half of the 
head and face, the most excruciating agony being referred 
to the occiput and right temple, and sometimes to the ball 
of the eye. The action of the heart now often faltered, 
the pulse being quick and fluttering, which, however, 
would be relieved by a free discharge of matter from the 
Ear, — there was a vacant stare occasionally, which made 
me suspect the brain was becoming affected ; she never, 
however, wavered in mind, nor was otherwise than most 
patients. In the worst period of the disease, the right 
tonsil and velum, as also I judge the Eustachian tube, 
being swollen, and inflamed, became much affected, in 
attempting to swallow more than a few drops ; at such 
times the liquid would flow suddenly from the nose and 
mouth. It appeared to me that from partial paralysis, 
the velum often failed to act, so that it required constant 
care to keep what she took from passing back by the nose, 
and at such times there was violent coughing-, When 
she put a watch between the teeth, she heard it somewhat 
better than when placed against the external Ear, but 
this was evidently fallacious, as one Ear was sound. At 
length a fungus formed in the external meatus, which 



148 



DISEASES OF THE EAR. 



subsided upon my opening the abscess near the mastoid 
process ; she had feverish irritation, but never anything 
like a fully developed fever. At one period of the disease 
she saw objects double, whether the sound eye was shut 
or open, evidently then with the diseased eye. A few 
days before her death, which was fourteen weeks from 
the commencement, paralysis though incomplete ap- 
peared in the upper extremities, the head and arms being 
affected with a palsied tremor, at length complete palsy 
and death resulted. Unfortunately there was no post- 
mortem examination, however, the symptoms clearly point 
out the material part of the case." 

It appears that in this case an abscess originated in the 
cellular tissue between the meatus and parotid gland, 
which in its extension ulcerated into the auditory canal, 
reached the cavity of the tympanum, and eventually the 
brain, the pressure upon the nerves in the neighbourhood 
having interrupted their function. (a) 

As consequences of such abscesses, when the ulcera- 
tions do not heal kindly, may be mentioned fistulous ca- 
nals and openings, by which the morbid secretion is main- 
tained, and fungoid granulations which encroaching upon 
the tube, increase the deafness. Acute external otitis 
frequently becomes chronic, which is to be considered 
further on. 

A follicular abscess of one or more of the ceruminous 
glands is not an uncommon occurrence ; the inflammation 
may be limited to the follicle diseased or extend along 
the canal, the amount of inconvenience depending upon 
the extent of inflammation and the size of the abscess, 



(a) " We doubt this pathology," says the British and Foreign 
Review, vol. viii.," and think that if any one will read carefully 
the case he will come to the same conclusion as ourselves regard- 
ing it, viz., that it was an inflammation and abscess of the tym- 
panum ; that the abscess burst through the membrana tympani, 
and also pointed at the mastoid process ; that the petrous bone 
and aqueduct of Fallopius, and, of course, the portio dura, became 
involved in the disease ; and, lastly, that inflammation extended 
to the brain or its membranes." 



OTITIS EXTERNA. 



149 



which may completely, or only partially occupy the audi- 
tory tube. 

Sometimes the general symptoms of external otitis, in 
cases of unusual severity are considerable, the febrile ex- 
citement running high ; in cases of less urgency, the symp- 
toms are nearly confined to the neighbourhood of the 
affected part. {a) 

The treatment of inflammation of the external meatus 
is to be conducted upon the usual principles ; if the local 
and the general symptoms are severe, and particularly if 
the individual be robust or plethoric, general bloodletting 
will be required, and sometimes even its repetition may 
be called for, although the majority of cases certainly are 
not sufficiently urgent to require this practice ; yet, when 
there is a probability that the disease may extend inwards, 
the surgeon will not hesitate to attempt its limitation by 
bleeding and every other means in his power. 

Leeches applied to the vicinity of the meatus, in num- 
bers depending upon the amount of inflammation, will 
be quite requisite in the majority of instances, and their 
repetition usually several times required. The back 
part of the Ear and the mastoid process may be consid- 
ered the most convenient position for their application, 
though they may be placed in front of the auricle, and 
generally about the angle of the jaw, particularly when 
a large number is employed. The experience ofltard 
leads him to believe that better effects are to be obtained 
from freely leeching the neighbourhood of the Ear, than 
from blood-letting. Brisk purgatives at first, and after- 
wards laxatives must be administered, as the most useful 

(a) External otitis is not un frequent in infants, in whom, often, 
its existence is not manifested very clearly. Disinclination to lie 
on the affected side, sudden cries and much agitation of the head 
may lead to suspicion, and to an examination of the ear. Red- 
ness of the part must not, however, be always expected. On the 
contrary, cases are met with in which the skin, made tenser by 
the resistance offered by the subjacent cartilage, is sometimes 
paler than natural. There will, however, be some tumefaction, 
and diminution, in consequence, of the size of the meatus ; mode- 
rate pressure, or even slightly twitching the ear, will cause pain 
and elicit cries from the child. 

19 



150 



DISEASES OF THE EAR. 



derivatives. Blisters behind the Ears, in every affection, 
are so constantly in use, that the practice has become al- 
most empirical ; it is, however, certain that in the differ- 
ent forms of external Otitis, when the more violent symp- 
toms have been reduced, or have naturally subsided, that 
the counter-irritation occasioned by a blister is often at- 
tended with marked advantage. 

Of topical applications, the combination of warmth and 
moisture by affording the greatest relief to the patients' 
sufferings must be considered the best.; thus fomentations 
over the whole Ear, and the temporal region, either medi- 
cated, as the decoction or infusion of poppy-heads, cha- 
momiles, marsh-mallows, &c, or warm water alone, and 
covering the part with a warm moist poultice of linseed- 
meal or bread, will be particularly useful after the leech- 
ing. Itard recommends during the first stages, and before 
the discharge has come on, the introduction into the au- 
ditory meatus of a solution of five or six grains of opium 
in some emollient decoction, as a most important assuager 
of pain ; but that this application, and all similar ones, 
are to be carefully avoided when the discharge has oc- 
curred ; as the interruption to such abnormal secretion 
may be followed by a rapid increase of inflammation, and 
its extension to the deeper parts, — at such a period he 
instils warm milk, or some emollient decoction, as plan- 
tain, mallows, &c. Injections of every kind, even the 
mildest, have a doubtful effect in acute disease of the 
outer Ear ; the mechanical injury produced by their in- 
troduction appears to be greater, than any advantage to 
be derived from them. Itard is in the habit of placing a 
soft piece of cotton, in which are enveloped about three 
grains of camphor, in the canal, with a view of affording 
relief. When the Otitis has subsided, or has become 
subacute, if the discharge continues, and does not appear, 
by its becoming daily thinner and less in quantity, to be 
subsiding, a very mild astringent lotion may be applied 
to the surface of the membrane, by being dropped into 
the tube, or upon a soft sponge ; the irritation of inject- 
ing may be too great. 

When an abscess has formed, and is projecting into 
the canal, relief will be expedited and the probable ex- 



OTITIS EXTERNA. 



151 



tent of ulceration lessened by the Surgeon puncturing it 
with a cataract needle or the Iris knife, as soon as he is 
quite satisfied of its existence, and that the projection is 
not occasioned by the tumefied membrane. In inflam- 
mation of the cellular tissue external to the meatus, reso- 
lution should be attempted by antiphlogistic means ; but 
when suppuration has unfortunately occurred, the sur- 
geon being anxious to prevent ulceration into the meatus, 
must open the abscess, in front of the mastoid process, 
behind or below the canal, as it may happen to point, 
as early as he can detect the presence of the fluid ; and 
even when he only suspects its existence, if he has good 
reason to expect suppuration, he will be justified in mak- 
ing an incision with his lancet ; and if he should fail in 
finding a collection, the cicatrix of the wound will even- 
tually ulcerate more readily, and the pus more easily 
escape, that when the skin is in its normal condition. The 
propriety of this practice becomes more apparent when 
the surgeon recollects the serious evil which may attend 
the extension of the abscess into the meatus, and proba- 
ble consequent danger to the membrana tympani. 

Kramer has arranged the diseases of the external audi- 
tory passage under the heads of — 1st. Erysipelatous 
Inflammation ; — 2dly. Inflammation of the Glandular 
Structure of the Meatus ; — 3dly. Inflammation of the 
Cellular Tissue; — 4thly. Inflammation of the Perios- 
teum. This division is useful to a certain extent, and 
every surgeon should bear in mind that each structure 
of the canal may be in certain cases the chief seat of in- 
flammation; but that acute otitis is likely to continue 
exclusively in any one structure during its entire progress 
is more than doubtful. In most cases, perhaps, the dis- 
ease commences in the glandular apparatus, but passes 
so rapidly to the cellular membrane, that the surgeon 
may not have had an opportunity of witnessing the affec- 
tion in its original seat. Dr. Kramer does not appear to 
employ the term Erysipelatous with the meaning that is 
usually adopted in this country, and which has been 
used by the writer, but to imply thereby a morbid secre- 
tion of wax, depending upon an erythematic condition 
of the dermal membrane ; as this state is rather chronic 



152 



DISEASES OF THE EAR. 



than acute, or even sub-acute, it will be considered in 
another section of this treatise. His second division is 
the Catarrhal, to which allusion has already been made ; 
in this section several other affections are described, some 
consequent upon the acute catarrh, and others indepen- 
dent of it, so that Kramer's somewhat severe criticism 
upon the mal-arrangement of other authors, may to a 
degree be applied to himself. The third division is the 
Phlegmonoid inflammation, which doubtless often occurs 
without involving the glandular structure, although that 
structure soon becomes implicated, unless the affection 
should be in the chronic form, and limited in extent, pro- 
ducing a very small abscess ; such instances are far from 
uncommon; very often they are consequent upon the 
disease of the mucous membrane, and frequently occur 
in the chronic form. Kramer's fourth section, inflam- 
mation of the periosteum, is a chronic disease, and, in 
most cases, if not in all, is consequent upon previous in- 
flammation in other structures. 

It is interesting to remark the similarity of predisposi- 
tion in structures formed at the same period of foetal life, 
or of childhood ; as two corresponding teeth on opposite 
sides of the jaw will become carious nearly at the same 
period in consequence of being alike affected during 
their formation : so it is often found that one ear being 
the subject of inflammation, the other, without evident 
cause, will become also attacked ; and that sometimes 
the affections of these organs will alternate with each 
other. The fact is notorious, that persons deaf in one 
ear are very liable to disease in the other ; which unfor- 
tunate predisposition is not solely to be referred to the 
circumstance of the sound ear being unusually exposed 
to the exciting causes, but in part, and perhaps mainly, 
to the same peculiarity occurring in both organs during 
their formation, which peculiarity will become permanent. 
Anatomists are in the habit of considering and describing 
as malformations those deviations only which are palpa- 
ble ; but pathology seems to teach us that malformations 
exist in the minute organization of different tissues, upon 
which may depend the various peculiarities and predis- 
positions to disease. These observations are not appli- 



OTITIS EXTERNA. ^53 

cable to the external ear only, but may include all the 
structures of the entire organ ; and this is doubtless the 
reason why diseases producing deafness are not often 
confined to one ear, unless the exciting cause be quite 
accidental. 

Bearing upon this point, the following case may be 
mentioned: — The writer was consulted by a medical . 
friend, in the winter of 1835-36. He had been deaf in 
the right ear for some years, in consequence of disease 
of the tympanum ; he writes that " he was now suffering 
from an attack of inflammation near the external meatus 
of the left ear, which produced for a fortnight perfect 
deafness, by obstructing the passage, and not (as was 
thought by some), by implicating the tympanum. It 
ended in suppuration, the matter burst into the meatus, 
and he soon recovered." The Author saw him about a 
week or ten days after the commencement of the attack, 
when it was evident that pus was being formed in the 
cellular membrane, external to the cartilaginous portion 
of the canal; after the ulceration had taken place, by 
pressure of the finger behind the auricle upon the edge 
of the mastoid process, the matter readily escaped through 
the opening into the tube. 

Allusion may be permitted to the following case, not as 
pointing to any peculiar circumstances, but as showing 
the ordinary progress of Otitis Externa arising from a 
specific cause : — Miss Janet R., about twelve years of 
age, had so severe an attack of scarlet fever, as seriously 
to endanger her life. The eruption extending along both 
meatus auditorii externi occasioned almost complete deaf- 
ness ; in a few days a copious discharge of yellowish- 
white matter, mixed with little flakes, took place. It 
soon assumed an exceedingly fetid odour, and continued, 
becoming more and more limpid and watery, during her 
convalescence, and several weeks after her perfect recovery. 
The flaky particles were doubtless exfoliations of the 
lining membrane. During the active stage the canals 
were simply washed out with warm water several times 
a day, with great relief to the little patient ; upon the 
subsidence of the acute symptoms, weak solutions of the 
sulphate of zinc, alum, and nitrate of silver, were alter- 



154 



DISEASES OF THE EAR. 



nately applied, and followed by a gradual lessening of the 
morbid secretion and restoration of hearing Upon ex- 
amining his patient two months after the cessation of 
the fever, and one month after all remedies to the ears 
had been relinquished, the author found her afflicted with 
a slight degree of deafness; the healthy secretion of wax 
was nearly restored ; the tympanic membrane of the left 
ear presented an ulcer at the lower and anterior part, oc- 
cupying about one-third of its extent, and the malleus 
apparently still possessing its normal attachment (Plate 
XII., fig. 11)- The membrane of the opposite ear was 
concealed by a small fungus, from which a muco-purulent 
secretion occurred. The hearing was more perfect on 
the left side than on the right. 

The reports of cases of Otitis Externa might be mul- 
tiplied, were further elucidation thought requisite, but un- 
fortunately their occurrence is so common, that every 
practical surgeon must frequently witness them. The 
Author may add, that his experience teaches him that 
scarlet fever is the most fruitful cause of inn 1 animation, and 
consequent disorganization, of the outer as well as the 
middle ear. 



Section III. 

INFLAMMATION OF THE MEMBRANA TYMPANI, 

When existing unconnected with disease of the tympanal 
cavity, may rather be considered as belonging to Exter- 
nal than to Internal Otitis. Such an insulation in the 
seat of inflammation has not been described by Itard, nor 
have Andral or Roche, in their very excellent articles on 
Otitis, alluded to it, except as a part of Otitis Interna. 
Dr. Kramer has a chapter on this affection, in which he 
treats of its acute inflammation, but more particularly 
dwells upon the chronic form. As the chronic disease of 
the membrane, and its consequences, are far from being 
rare, without evidences of a coexisting affection of the 
meatus, or of the tympanum ; and as symptoms are occa- 
sionally presented to us, which would be expected to arise 



INFLAMMATION OF THE MEM BRAN A TYMPANI. 



155 



from vascular excitement of this membrane, and in the 
course of a few days pass off, leaving no recognizable 
organic change, it appears reasonable to consider that an 
exciting cause may be applied to, and produce its effects 
in, the membrane, without implicating either the meatus 
or tympanic cavity. Kramer seems to have settled the 
question by direct experience ; though he formerly, with 
other surgeons, thought the disease was always compli- 
cated with other affections. Most certainly it generally 
occurs as an extension from the auditory canal, which 
circumstance is to be expected, inasmuch as the same 
cuticular covering is reflected upon both. 

When inflammation occurs in the tympanic membrane 
exclusively, the patient suddenly feels an acute pain at 
the bottom of the meatus, following the application of 
some irritant, which is generally cold wind striking 
sharply against the membrane, or the introduction of 
some foreign body, or perhaps a mechanical injury result- 
ing from the removal of hardened wax or a foreign sub- 
stance; or it may possibly be occasioned by too great a 
degree of vibration in consequence of unusual strength 
in the sound applied. The pain is accompanied by buz- 
zings, as though something were fluttering in the ear, 
and by a lessened capability of hearing : and it is increased 
by loud sounds, by variations of temperature, and by pres- 
sure upon the ear; it becomes now and then unusually 
severe, which will continue for a few minutes, or some- 
times much longer. When the membrana tympani is 
examined, with the assistance of a speculum and good 
light, it is found, in mild cases, to be slightly reddened, 
and vessels may sometimes be distinguished upon its sur- 
face. In severe cases the membrane will present an uni- 
versal blush, and blood-vessels will be readily seen ; it 
will be swollen and thickened, and the attachment of the 
handle of the malleus imperceptible. The milder degree 
of inflammation, which may be termed subacute, rarely 
excites general symptoms; and in the course of a few 
days the disease will subside. In the severe cases the 
local symptoms will be aggravated, with diminution of 
the ceruminous secretion of the meatus, which canal 



156 DISEASES OF THE EAR. 

otherwise retains its natural appearance; and fever will 
be produced. 

The consequences of a higher degree of inflammation 
of the membrane, or when the affection has been long con- 
tinued, may be anticipated. The disease may extend to 
the meatus, or inwards to the tympanal cavity; — the 
membrane may become thickened by the adhesive inflam- 
mation, either throughout its whole surface, or in several 
spots, presenting a rugged appearance, and which being 
vascular, may resemble indurated granulations : — a fun- 
gous growth may arise, w T hich is however much more 
frequently produced by the chronic disease : little scales 
often exfoliate from the surface ; — the affection may ter- 
minate in ulceration, injuring to a greater or less extent 
the cavity of the tympanum; — lastly, chronic disease 
may supervene. 

It would appear from this history that the disease is first 
seated in the external cuticular membrane ; and in its 
progress, or severer form, extends to the fibrous tissue. 

This is the form and seat of inflammation, which has 
frequently been described as Otalgia or Ear-ache, which 
term we have seen has been applied to all acute diseases 
of this organ. The sudden accession of the pain, and its 
frequent subsidence without medicinal aid, with the dif- 
ficulty in many instances of obtaining a good view of the 
state of the membrane, may afford an excuse for the sur- 
geon considering it purely neuralgic ; and even Itard, 
with his great experience, seems to have fallen into this 
error. It very probably, however,takes somewhat a neu- 
ralgic character, as in the milder cases the vascular ex- 
citement does not appear to correspond to the amount of 
pain, and of general sensibility of the organ, and the ner- 
vous connections of the membrane will favour such sus- 
picion. 

In the treatment it is of much importance not to mis- 
take the inflammatory character of the disease, as the in- 
troduction of opium and other narcotics, which will bene- 
fit pure neuralgia, will here increase the excitement. In 
slight cases, the application of warmth and moisture over 
that side of the head — the maintenance of an equal tern- 



OTITIS INTERNA. 



157 



perature — the action of a purgative — and, if there be 
no fever denoting increased action, an opiate at bed-time, 
particularly in the form of Dover's powder, will be gene- 
rally successful in removing the malady. The more se- 
vere cases will demand the application of leeches to the 
neighbourhood ; and the severely acute affection will re- 
quire the strictest antiphlogistic regimen, both surgical 
and dietetic, including bleeding, as well general as local, 
with free purging, blistering, &c, to obviate the unfor- 
tunate consequences which may otherwise ensue. If the 
acute disease should continue, notwithstanding the treat- 
ment administered, by which ulceration or induration and 
thickening are threatened, the timely and judicious use 
of mercury to salivation may be attended by the same 
happy results, which are so conspicuous upon its admin- 
istration in Iritis. 



Section IV. 

OTITIS INTERNA. 

This term evidently should include inflammation of 
the labyrinth ; but, as the immediate effects of acute dis- 
ease in this intricate structure are not recognisable, and 
as they are only suspected in consequence of the cophosis 
produced, it has generally been confined to inflammation 
of the tympanum, where the disease may be early de- 
tected by attentive discrimination, and where its effects 
become apparent to every observer. It should therefore 
rather be called Otitis Media. That acute inflammation 
of the tympanal cavity occurs, commencing ordinarily 
in its mucous membrane, and extending to the other struc- 
tures, almost every day's experience convinces us. Dr. 
Kramer has arranged it under two heads, that of Inflam- 
mation of the Mucous Membrane with Mucous Accumu- 
lation, and that of the Sub-mucous Cellular tissue; which 
arrangement corresponds to Itard's Catarrhal and Puru- 
lent Internal Otitis. This division is with difficulty re- 
cognised in the majority of acute cases, and experience 
leads the author to justify the criticism of M. Itard's re- 

20 



158 



DISEASES OF THE EAR. 



viewer in the Edinburgh Journal. The arrangement may 
be dangerous, if the partial, yet still excellent history 
given by Kramer, of a form of sub-acute inflammation of 
the mucous membrane, be received and acted upon as 
that which constantly occurs. He has written a good ac- 
count of a frequently occurring condition of this tissue, 
but does not appear to have dwelt sufficiently upon its 
rapid extension : which extension he seems to imply, only 
takes place from the sub-mucous structure. As it is seen 
that the sub-mucous tissue may be inflamed without the 
surface of the membrane being involved in other parts 
of the body, and particularly in the meatus auditorius, 
which, however, must be considered as a comparatively 
rare occurrence, so it may be imagined that the cellular 
membrane of the tympanum may be the seat of phleg- 
mon, independently of the rest of the tissue, but that it is 
not so frequent as Dr. Kramer appears to believe the his- 
tory of most of the cases seems to prove. The inflamma- 
tion generally commences in the mucous membrane, and 
may or may not extend to the structures beneath, or it 
begins simultaneously in both, and in its course may reach 
and destroy the periosteum and bone. 

Every experienced practitioner of aural surgery must 
have seen two varieties of tympanal otitis ; one slow in 
its progress, comparatively mild in its symptoms, and fre- 
quently recovered from; the other most severe, rapid, 
and generally destructive, either to the tympanum or the 
life of the individual. These varieties are rather to be 
considered as in degree, than in structural situation ; and 
therefore it would appear, that if they are to be esteemed 
as distinct diseases, the appellations of Itard are prefera- 
ble to those of Kramer. Mr. Saunders divided the com- 
plaint into three stages, without attempting to separate 
the disease itself: — 1st, A simple puriform discharge; 
2d, A puriform discharge, complicated with fungi and 
polypi; 3d, A puriform discharge, with caries of the 
tympanum. These conditions are merely the effects of 
inflammation; and are rather to be considered as chronic. 

The causes of internal otitis resemble those of the ex- 
ternal disease ; the most common is undoubtedly cold, 
applied through the Eustachian tube, — or perhaps 



OTITIS INTERNA. 



159 



through the membrane, — or generally to the side of 
the head ; the extension of inflammation from the tonsils 
or the fauces, from the external Ear through the Mem- 
brane, or from the membrane itself, — from the mastoid 
cells, though the reverse is generally observed; such 
spreading particularly occurs in the exanthemata ; the 
affection arises also from an injury, accompanied or not 
with laceration, of the membrana tympani ; and from 
mechanical irritation of the mouth of the Eustachian 
tube ; disease extends to the tympanum likewise from 
the brain, whether the original complaint be spontaneous 
or traumatic ; and it is excited by irritating medicinal 
applications when the membrane has been removed : 
mechanical violence may be applied to this cavity as else- 
where : but by far the most frequent cause is a cold 
wind blowing along the meatus, in a predisposed subject ; 
in which event, the meatus is defended by its secretion 
from the effects of the direct application of the same 
draught of cold air, which indirectly affects the tympa- 
num to serious disease. It is asserted that the sudden 
suppression of a distant discharge will excite disease in 
this cavity, corresponding to the supposed similar effect 
in the external Ear; and that it alternates with ophthal- 
mia. It is quite certain that disease of the Ear, both in- 
ternal and external, frequently accompanies, and appears 
to be in some measure modified, by affections of the eye ; 
they are generally confined to the mucous membranes of 
both organs; are produced by the same exciting causes, 
and almost invariably occur in scrofulous children. A 
common opinion prevails, that loud noises, as the roaring 
of cannon, will break the drum of the Ear, and produce 
all the consequences of tympanal suppuration ; it is not 
uncommon to meet with otorrhoea, from disease of this 
cavity, in old soldiers, but other causes than the noise of 
cannonade, have been in operation, to which the dis- 
ease may be rather attributed. The rupture of the drum 
of the Ear, so often complained of, as being produced by 
the breaking of stones at the road side, ought with more 
propriety to be considered as an affection of the nervous 
portion of the organ ; and the discharge that sometimes 
accompanies the deafness to be attributed to other exciting 



160 DISEASES OF THE EAR. 

causes. Scrofula is the great predisposing cause of 
internal otitis, which is not commonly met with in indi- 
viduals, who have not this peculiar delicacy of constitu- 
tion, excepting when excited by accidental causes. In 
like manner syphilis, and all debilitating diatheses, pre- 
dispose to this affection. 

It will be advisable to treat first of the severer degree 
of inflammation, with its acute effects ; and then to dis- 
cuss the milder, but very often the more insidious form 
of this disease. 

§ The symptoms of the severe affection, to a certain 
extent, resemble those of otitis externa, differing in conse- 
quence of the structure affected ; of their greater severity ; 
and of the circumstance of the matter when formed not 
meeting with a ready outlet. The symptoms are at one 
time ushered in by a severe pain in the Ear, which is 
often neglected, and regarded as being what is commonly 
termed Ear-ache, and which may continue only for a 
few hours, or it may persist with occasional exacerbations, 
for two or three days ; when it more or less suddenly ex- 
tends to the whole of that side of the head. In other cases 
the symptoms commence with intense headache or in- 
supportable hemicrania ; the febrile excitement is most 
severe, the eyes are injected, watery, and intolerant of 
light; the countenance is flushed and anxious; the skin 
hot and dry ; the pulse frequent and hard ; the secretions 
are suspended ; the pain becomes excessive, and extends 
throughout the whole head, but is more severe on the side 
affected, and the patient particularly refers, as the most 
painful part, to the bottom of the auditory canal ; tinnitus 
aurium is a frequent distressing accompaniment ; the pain 
is increased by noises, even the slightest, by the move- 
ments of the jaw, and attempts at deglutition ; and it fre- 
quently shoots through the brain, and extends to the 
fauces ; the disease is attended by delirium, often very 
violent at the onset, but towards the close becoming low 
and muttering, and by occasional rigors. In its progress, 
the inflammation spreads to the mastoid process, which 
becomes hot and painful on pressure, as well as to the 
pharynx, tonsils, &c, which are then tumefied and red- 



OTITIS INTERNA. 



161 



dened. The severity of the symptoms frequently abates 
in the morning, a reaccession often accompanied by rigors 
coming on in the evening. The patient is also deaf on 
the affected side. 

So far the symptoms, though indeed acute, are insuffi- 
cient to distinguish inflammation of the tympanum, from 
the most severe form of external otitis : to perfect the dia- 
gnosis, it is necessary to ascertain that the auditory canal 
is free from disease ; and to take into consideration the 
longer interval of time between the first accession of pain 
and appearance of discharge. In external otitis the muco- 
purulent secretion occurs in a few days, or even a few 
hours ; in the internal disease, a week or more will elapse 
before any matter is discovered, and then it escapes sud- 
denly either through a rupture of the membranatympani, 
through the Eustachian tube, or through the ulcerated 
mastoid cells ; whereas in the external disease it is pre- 
ceded by a serous moisture. 

This may be considered as the first stage of the disease, 
and is that of inflammation, terminating in suppuration. 
It sometimes happens that timely treatment in a good 
constitution so lessens the inflammation, that it termi- 
nates in a mucous secretion, or in resolution ; but in the 
great majority of instances, it passes on to suppuration, 
and the escape of the pus may constitute the second 
stage. 

The distressing symptoms are not relieved when sup- 
puration is completed, in consequence of the pus being 
still retained in the tympanal cavity ; no certain data 
therefore exist, by which it can be known that the secre- 
tion has taken place, until it makes its exit, which may 
happen in a week, or it may not occur until after two or 
three weeks. 

The pus is discharged most frequently through the 
membrana tympani, either by rupture, to which it may 
be more prone in consequence of its inflamed condition ; 
or, which is more common, by means of ulceration, and 
which often takes place to a great extent. Itard has sup- 
posed that the greater frequency of the matter being dis- 
charged through the membrane than the Eustachian 
tube is as ten to one. The first stage of the inflamma- 



162 



DISEASES OF THE EAR. 



tion generally closes the Eustachian tube by adhesion, 
and hence the difficulty of the matter finding its exit in 
that direction. When the suppuration has extended 
back to the mastoid cells, the integument covering the 
process assumes a dark livid colour, often attended with 
an indistinct fluctuation; ulceration, or even sloughing 
may occur, or the abscess be opened artificially, when the 
matter mixed with blood finds an escape, accompanied 
by exfoliations of the cells. The pus in all cases is 
offensive, and particularly disagreeable to the taste when 
it passes into the throat; occasionally the ossicula are 
discharged at the same time through the membrane or 
mastoid process, but they usually come away at a subse- 
quent period. 

When the case is favourable, the patient experiences 
a subsidence of his distressing symptoms as suddenly as 
the escape of matter occurs, and the improvement is in 
proportion to the freedom of the discharge, which varies 
either in consequence of the great consistence of the 
matter closing the opening in the membrane, or of in- 
spissated fibrin, in the form of little crusts falling against 
the aperture. On examination of the Ear the perfora- 
tion may be generally seen, but sometimes that is im- 
possible, in which case, however, air may usually be 
forced through it from the Eustachian tube, forming 
bubbles in the matter; the absence of this sign is not to 
be depended upon, as a closure of the tube will pre- 
vent the success of the experiment. When the pus finds 
its way through the tube, by forcing through the obstruc- 
tion, or by ulceration, the quantity is sometimes so great, 
and so suddenly discharged, as to resemble the breaking 
of a tonsillitic abscess, and the muco-sanio-purulent matter 
is expectorated ; at other times it escapes by degrees, and 
there is a constant disagreeable sensation in the throat, 
with continual spitting. Happy results may be expected 
when the matter is discharged into the throat, but when 
it escapes into the meatus, or through the mastoid pro- 
cess, it is almost certain that the ossicula, wholly or in 
part, will be lost, and that a troublesome chronic otorrhoea 
will continue for a long period, sometimes even during 
life, giving rise to deafness more or less complete, the 



OTITIS INTERNA. 



163 



extent of which depends upon the amount of disorgani- 
zation. This part of the subject will be more advanta- 
geously considered, in treating of the chronic diseases of 
the tympanum. 

It but too frequently happens, that the Surgeon wit- 
nesses an unfavourable termination to this painful form 
of disease ; the severe symptoms assume those characters 
indicating inflammation of the membranes of the brain, 
and after passing some hours, or a day or two, in a state 
of delirium more or less raving, the patient falls into a 
condition of coma and expires. The symptoms alone are 
sufficient evidence that the disease has extended to the 
brain, and it appears, in most instances, to make its way 
either through the roof, or the posterior wall of the tym- 
panal cavity. In cases where this result is very rapid, 
the inflammation may extend from the lining membrane 
of the tympanum to the bone, and thence to the dura 
mater, and thus life may be destroyed by meningitis, or 
phrenitis ; while in other cases the disease may termi- 
nate in suppuration either between the cranium and the 
dura mater, or between the cerebral membrane themselves, 
or in the substance of the brain. Dissections of these 
cases, however, prove that the upper or posterior wall of 
the tympanum is generally destroyed, either by necrosis, 
or more frequently by caries, which condition corresponds 
to the more gradual extension of the disease to the brain ; 
and particularly to the fact, that these fatal cases usually 
result from acute inflammation excited in a chronic affec- 
tion. 

As examples of the acute form of tympanal inflam- 
mation, the following cases may be inserted. The first 
history is given in the words of the Surgeon who at- 
tended the patient throughout. 

" Miss M. N., aged five years, born of scrofulous pa- 
rents, had been subject to pain in the Ear for two years, 
which subsided with a discharge from the meatus, and 
was considered by her friends as a common Ear-ache, to 
which no treatment was directed beyond a poultice and 
warmth. It was observed by her mother than when free 
from the pain, she always had a discharge from an erup- 



164 



DISEASES OF THE EAR. 



tion behind the Ear. This little girl, with slight pre- 
vious indisposition, was momentarily seized, on the 21st 
March last, with sickness and convulsions, which lasted 
for more than an hour ; she was quite sensible and reco- 
vered when the Surgeon saw her, and no trace nor evi- 
dence of epilepsy remained. From the description of the 
attack it was thought right to bleed her, and to direct the 
almost daily application of leeches, with mercurials and 
aperients. For some days she appeared cheerful, and 
seemed to be going on well for a week, when she grew 
less cheerful and restless at night, complaining of pain 
in her Ear ; now active treatment was instituted ; and 
leeches to a great extent, with calomel in large and re- 
peated doses, and continued blisters at the side of the head 
and behind the Ears, failed to give the least relief, and 
she died comatose, with all the symptoms of matter on 
the brain on the 20th April. The pupils were fully di- 
lated, and sensibility to light was lost ; the pulse from 
thirty to forty, sometimes hurried, and then sinking down 
to that standard, generally irregular, as if the heart had 
no power of acting ; the pain, so long as the little sufferer 
was sufficiently sensible to make it known, was always 
referred to the affected Ear. The head was not allowed 
to be examined, but the evidence of scrofulous disease 
was so strongly marked, that the attendant feels confident 
of the existence of suppuration, communicated by inflam- 
mation of the internal cavity of the Ear to the dura 
mater." 

It is exceedingly unfortunate that a post-mortem in- 
spection in this case was not permitted, as though no 
doubt can exist that it would only have furnished another 
to the many instances, of disease extending from the 
tympanum to the brain, which are found reported in the 
records of our profession, yet it would have been inter- 
esting to have noted the exact extent and situation of 
such lesion; this case affords another example of the 
general strumous tendency of individuals thus afflicted. 

A professional friend, to whose case of suppuration 
into the meatus allusion has already been made, fur- 
nishes this history of the loss of his hearing in the right 
Ear : — 



OTITIS INTERNA. ^55 

" In the autumn of 1828, I was in a very weak state 
of health, in consequence of the confinement of my 
apprenticeship, and the loss of the constant and free ex- 
ercise in the open air, which I had always before en- 
joyed, and something may be attributable to an alteration 
of diet. While attending the funeral of a dear relative, 
and suffering from distress never before experienced, I 
was exposed to a current of keen wind upon my right 
Ear. I experienced pain in it, which on the second night 
became very acute, and in the morning I found a dis- 
charge of pus from the meatus ; this discharge continued 
for a length of time, sometimes offensive, sometimes not, 
and the malleus at last was lost, which I kept for some 
time. I think the other bones are away also, for I am 
perfectly deaf of that Ear. I remember that when I 
sometimes from uneasiness pressed the meatus from be- 
hind, and forced the pus through the Eustachian tube, 
I had a sense of giddiness in my head, as if there were 
pressure upon the brain. The discharge continued more 
or less, during all the following winter, and in the next 
summer I had a large abscess behind the Ear, which 
was long troublesome. At length this healed, and the dis- 
charge from the meatus diminished, and at last ceased 
entirely." 

Upon examination of the affected Ear, the Author finds 
that fungoid granulations have sprung up from the tym- 
panum, and bottom of the meatus, which so far obliter- 
ates and protects the cavity, as to render its inner wall 
imperceptible, it is therefore impossible to say whether 
the stapes is removed or not ; although the patient thinks 
it is, yet, as vibrations communicated through the bones 
of the head are distinctly heard on that side, it is more 
than probable that the ossiculum still remains, as its ex- 
foliation is generally, though not always, attended with 
ulceration or laceration of the membrane of the fenestra 
ovalis, and consequent loss of the aqua labyrinthi. 

" J. B., aetat. 21. — Housemaid, of short stature, very 
dark complexion, and strumous appearance, had been 
long subject to violent Ear-ache, and pains in the head, 

21 



166 



DISEASES OF THE EAR. 



and on one occasion previously to her last illness, a quan- 
tity of blood came from her Ear. On a Monday, in April 
1838, whilst out walking, she was attacked with severe 
pain in the right Ear, which was accompanied by a con- 
siderable discharge of blood from the meatus. (She 
thought the blood was pure and unmixed with matter.) 
Leeches were applied to the head but gave little relief, 
and on the same evening, or on the following morning, 
blood was taken from the arm with apparent benefit. 
On Tuesday evening she said that the pain, although 
still severe, was diminished ; at a latter hour she became 
excited and restless, talked almost incessantly, and in a 
wandering manner, and insisted upon leaving her bed 
and going down stairs. From this time she became 
worse, and on the Saturday following was conveyed to 
the house of a relation, still complaining of much pain in 
the Ear and side of the head. She had become exces- 
sively weak and drowsy. The tongue was loaded and 
rather dry. In fact, typhoid symptoms were commenc- 
ing. She died rather suddenly early in the afternoon 
of the Monday or Tuesday following. 

" No post-mortem examination was made. 

" It was stated soon after her death by her fellow-ser- 
vant, that she was much accustomed to spirit drinking.' , 

This case, which towards its close, was mistaken for 
contagious fever, though evidently Otitis extending to the 
brain, is important as denoting the facility with which 
the original disease may be overlooked. 

" S. R., setat. 12 years, an apparently healthy girl, had 
been the subject of attacks of pain and deafness in the 
right Ear for the last twelve months, recurring every two 
or three months, and lasting for a day or two, but without 
any discharge, the pain extending to the back part of her 
head on that side, but not so severely as to attract serious 
attention until last Sunday, October 23d, 1831, when a 
more severe attack accompanied with a discharge com- 
menced, and was imputed by her mother to the child 
having taken cold after being in a shower of rain without 
any covering to her head. When first seen on the morn- 



OTITIS INTERNA. 



167 



ing of Friday, October 28, she was sitting up with her 
head reclining on the right side, and complaining of great 
pain in the Ear from which there was a purulent discharge ; 
there was pain on pressure behind the Ear, more parti- 
cularly over the mastoid process, and slight redness about 
the tonsils and uvula, though she had never complained 
of uneasiness in the throat, or any difficulty in degluti- 
tion. There was anxiety of countenance, a quick pulse, 
and general febrile excitement. For the three following 
days the symptoms remained unabated. The pain over 
the mastoid process had increased, and on Nov. 1st a 
puffiness was there detected ; on Nov. 2d, fluctuation 
behind the Ejar having become evident, a puncture was 
made, and a quantity of stinking purulent secretion dis- 
charged. She had had a distinct rigor in the morning, 
and the fever continued with extreme restlessness and. 
anxiety of countenance. Nov. 3d, continued much the 
same until this evening about eight o'clock, when she 
had a convulsion lasting only a minute or two, but re- 
mained insensible for a short time after. On visiting 
her about half an hour afterwards, she was lying on the 
left side, breathing quickly and anxiously, the pulse ex- 
ceedingly hurried, and occasionally irregular and inter- 
mittent. Pupils natural and sensible to light. Tongue 
furred and white, — had an involuntary stool just before 
the convulsion, — complained to-day of difficulty in swal- 
lowing, for the first time, — the countenance expresses the 
greatest anxiety, and she is moaning with pain. The 
Ear discharges abundantly, as well as the opening made 
behind it. Had another rigor this morning, — shuns light 
and conversation as if it annoyed her. Nov. 4th, no re- 
turn of the convulsion, but she is lying in a partially 
comatose state, seeming disinclined to answer questions, 
and speaking hurriedly. The countenance still expres- 
sive of the greatest anxiety, — tongue white, general py- 
rexia and thirst. Bowels open twice to-day, pulse quick 
but not irregular, nor intermittent as yesterday, — com- 
plains of great pain down the back, and in all her limbs, 
— a quantity of fetid pus discharged by pressure from 
behind the Ear. This morning, Nov. 5th, — all the symp- 
toms continue unabated, with great restlessness and irri- 



Igg DISEASES OF THE EAR. 

tability, constantly crying with pain Tongue has now 
become red and glazed ; bowels had been once opened. 
Nov. 6th, — Died this morning, (Sunday,) about ten 
o'clock, having continued sensible until her death, but 
lost her speech for six hours previously. 

"Autopsy twenty hours after death. — Small abscess 
under the pericranium in a line with the longitudinal 
sinus. The cellular structure under the occipito-frontalis 
muscle inflamed, and abscess behind the right Ear. The 
vessels of the membranes of the brain much congested. 
The pia mater covering the inferior edge of the middle 
lobe of the cerebrum much thickened, and a small quan- 
tity of pus effused under it. A large abscess in the right 
lobe of the cerebellum produced by ulceration of the pe- 
trous portion of the temporal bone, which had ulcerated 
from the cavity of the Tympanum and the Mastoid cells, 
just above the grove for the lateral sinus ; the dura mater 
was found separated from the bone at that part by pus 
effused beneath it." 

" Mr. J. V., aged twenty-seven years, had been the sub- 
ject of suppurative discharge from the right meatus audi- 
tor] us from the age of fourteen, accompanied by occa- 
sional pain in the ear, and about that side of the head. 
In January, 1822, he had an attack of severe pain about 
the ear, and a large abscess formed behind it, burrowing 
under the temporal fascia. This was opened and all did 
well. He frequently complained of pain, but not so severe 
as to induce him to seek medical relief, and also had a 
constant discharge from the Ear, which was occasion- 
ally peculiarly offensive. At this time I was spoken to 
on the subject, and recommended hi mSto frequently syringe 
the Ear with warm water, and not to neglect a severe pain, 
he might at any time experience. On Saturday, August 
14th, 1830, 1 was requested to see him, and was told that 
he had taken opening medicine for a day or two, and that 
he believed he had taken cold whilst bottling wine in a 
damp cellar. He now complained of headache, and his 
pulse was frequent and skin hot. Leeches were ordered 
to be applied to the head, and a purgative with saline 



OTITIS INTERNA. 



169 



medicine prescribed. He was found much in trie same 
state for several days subsequently, but on the evening of 
the 20th, all his symptoms became more distressing, there 
was a degree of stupor with great restlessness, and the 
pulse was extremely small and weak. On the 21st he ap- 
peared somewhat relieved, and much more easy and tran- 
quil. 22d. — There was now considerable want of power ; 
his pulse was feeble but not frequent, the tongue dry and. 
of a brownish colour. The bowels had been opened. On 
the 22d, in the evening, he seemed much worse, having 
considerable pyrexia with coma and restlessness. Leeches 
were again ordered to the head, and small doses of mag. 
sulph. every four hours. 23d. — Still evidence of consi- 
derable head affection, — and comatose ; he could be 
roused when spoken to, and appeared conscious for a 
short time, but would soon relapse into the same stupid 
condition. Up to the 29th he went on much in the same 
manner. The bowels, however, became very torpid, for 
which enemata were used. Leeches and evaporating 
washes to the head were had recourse to. 30th. — The 
head very much affected, and was extremely hot to the 
hand. At this time there was a trifling discharge from 
the right Ear, and in the night he had a distinct rigor, 
which was followed by coma. 31st. — He was coma- 
tose, the surface of the body cold, more particularly the 
hands and feet, he was breathing stertorously, the pulse 
extremely feeble, and the bowels very inactive. In the 
evening reaction took place, the head extremely hot with 
very great restlessness, the pulse very quick, and the 
tongue dry and brown. Sept. 1st. — Appearing much 
in the same state, — the bowels had not acted, the pulse 
feeble and about eighty in the minute, hands and feet cold, 
great restlessness with stupor. On the evening of the 
2d, he was attacked with considerable embarrassment in 
his breathing, which continued some time ; otherwise, 
he went on much in the same manner, and died on the 
morning of the 3d about ten o'clock. 

"Autopsy at seven in the morning of the 4=th. — The 
membranes of the brain presented nothing unusual, — 
there were about two ounces of clear serum in the ven- 



170 



DISEASES OF THE EAR. 



tricles ; on drawing the crura cerebri and cerebellum 
backwards with the view of cutting through the medulla 
oblongata, the pressure of my fingers on the right lobe of 
the cerebellum burst an abscess, and a large quantity of 
offensive dark coloured pus escaped. On closer exami- 
nation the dura mater was found separated from the pos- 
terior face of the petrous portion of the temporal bone, 
which was in a state of ulceration communicating with 
the cavity of the tympanum. 

" In the above case, the slow state of the circulation, 
and the torpid condition of the bowels, and the formida- 
ble disturbance which took place towards the end of the 
case to the respiratory process, are points which should 
be borne in mind, and occupy our thoughts." 

These two cases, which were supplied to the author 
by the same friend, clearly illustrate the usual course 
of acute Otitis of the middle Ear, excited upon a 
chronic disease, and extending its ravages to the sen- 
sorium. 

" Miss B., setat. 9. — Had never been of a strong habit, 
but on most occasions had enjoyed perfectly good health 
until three years since, at which time she laboured with 
scarlatina. After her recovery she became subject to 
pain in the left ear, accompanied with deafness, and a 
discharge of thin purulent matter of a fetid odour. The 
deafness increasing, her friends consulted an aurist, who 
ordered an injection, a strong solution of sulphate of 
zinc, to be thrown into the ear, and the use of it to be 
continued for some time ; however, the benefit derived 
from it was trifling. On Monday, the 19th of March, 
1838, the injection having been continued about a month, 
the pain in the ear became more acute, and extended 
somewhat higher up the side of the head than at former 
periods, and it was increased on pressure being applied 
over the mastoid process of the temporal bone, — pulse 
eighty and compressible. 20th. — The pain is more 
severe than yesterday, and it extends over the greater 
portion of the left side of the head ; complains also of her 
eyes being weak, and not able to bear the light of a can- 



OTITIS INTERNA. 



171 



die. 22d. — The right pupil is somewhat more dilated 
than the left, still, however, obedient to light , there is 
also an involuntary movement of the arm and leg on the 
right side, but during the intermission of the latter, she 
still retains power over them. About nine o'clock, p.m. 
she called for some coffee, which was immediately re- 
jected from her stomach, — pulse 70, compressible and 
laborious. 

" She continued perfectly sensible until one o'clock 
the next morning, when she expired. 

" Autopsy. — Permission was obtained to examine the 
head only. The bones of the head were remarkably 
healthy, with the exception of the petrous portion of the 
left temporal bone, the anterior surface of which was of 
a dark red colour from increased vascularity, the poste- 
rior was slightly ulcerated. After sawing it through to 
expose the internal Ear, the aural surface of the petrous 
portion was pretty generally coated by puriform matter, 
and the membrane lining the meatus auditorius externus 
was in several places even ulcerated. 

" The tympanum and the labyrinth of the ear appeared 
to have suffered from ulceration, which had been in pro- 
cess for some time. A cavity had formed within the 
mastoid process, which contained about a drachm of 
puriform matter of a fetid odour. 

" The dura mater of the brain was pretty healthy, 
with the exception of a part of it immediately in contact 
with the petrous portion of the temporal bone, w T here it 
was firmly adherent, and required some force to separate 
it ; it was also thick, dark in colour, and covered with 
puriform matter. 

"The arachnoid membrane throughout presented a 
slight degree of opacity, and beneath it there was a con- 
siderable quantity of serum effused, and the portion sur- 
rounding the diseased bone, was thickened and covered 
with lymph, which was principally within its cavity. 
The pia mater was increased in vascularity, and somewhat 
more adherent to the brain itself. The convolutions of 
the cerebrum were well developed, and by no means de- 
pressed, whilst on making an incision into the hemisphere, 



1 72 DISEASES OF THE EAR. 

they appeared increased in vascularity. The right and 
left lateral ventricle each contained about four drachms 
of transparent serum. That part, the left lobe of the cere- 
bellum, which lay in contact with the diseased bone, was 
nearly altogether softened, and formed into one continu- 
ous mass, which was pretty free from any admixture of 
puriform matter, whilst the remaining undestroyed por- 
tion of the lobe was increased in vascularity, and in a state 
approaching to softening." 

The fatal consequences of improper interference with 
chronic disease of the exposed tympanum, is well illus- 
trated by this case, in which it appears that the membrane 
being ulcerated, the astringent lotion was introduced into 
the tympanic cavity, which it excited to active disease. 
Within a few days the Author was consulted by a gen- 
tleman, who had suffered severe pain from the introduc- 
tion of some drops into his ear by an aurist in extensive 
practice ; it was ascertained that he had a large aperture 
in the membrana tympani. 

To these cases of acute inflammation of the tympanum, 
several others might be added which have fallen, either 
directly or indirectly, under the notice of the Author of 
this paper, as well as many admirably reported by Dr. 
Abercrombie, by M. Itard, and by Dr. Duncan and other 
writers, in the different journals; but as most of them 
have supervened upon chronic disease of the tympanum, 
it will be better to make brief allusions to some of them 
when treating of that part of our subject. It may be 
permitted, as elucidating another mode of termination, to 
transcribe a case which Dr. Kramer has quoted from 
Schmucker : 

" A soldier, named Hittberg, had suffered for many 
years from pain in his ear, discharge of pus, and great 
difficulty of hearing. Notwithstanding this, he was ap- 
pointed to his regiment ; but three weeks afterwards, he 
had violent fever and dreadful pain in the right ear. In 
the left ear the pain was supportable. A bleeding, — 
emollient poultices to the right ear ; a second bleeding, 
— blisters, and enemata, in some measure diminished the 



OTITIS INTERNA. ^73 

pain, which, however, always returned, though the dis- 
charge was never interrupted. During the most violent 
pain, a blister had been applied to the mastoid process of 
the affected side, and thus a slight elevation had been in- 
duced over this spot, which indistinctly fluctuated. Af- 
ter repeated applications of emollient poultices, an inci- 
sion was made through the swelling, an inch long, down 
to the bone. The bone was rough, worm-eaten, and pre- 
sented an opening, from which, however, only a small 
quantity of pus escaped ; but on introducing a syringe, 
and injecting some pectoral infusion, pus escaped through 
the Ear into the mouth, accompanied by a very peculiar 
sensation. Great relief from the pain in the head followed 
immediately on this ; the opening in the wound dis- 
charged a good deal of pus. The wound was dressed 
with dry lint, and the depuratory injections were repeat- 
ed daily ; in eight days the discharge had ceased, and in 
three weeks the wound of the integument was healed. 
The patient never experienced pain in the head again, 
and his hearing, compared with what it had previously 
been, was even much better." 

The treatment of the severe form of acute internal otitis, 
whether it be primary or consecutive, must be conducted 
on the strictest antiphlogistic rules ; bleeding generally 
and locally, until an effect is produced upon the symp- 
toms, or at least upon the pulse; blisters in the neigh- 
bourhood of the head, and when the more severely acute 
pain in the Ear has been diminished, they may be ap- 
plied behind the auricle, and often with great benefit ; 
cathartics, even somewhat of an irritating character, are 
requisite as depletants, and also as derivatives ; and if the 
disease threatens to be obstinate, or to extend, which in 
the majority of these serious affections will occur, mercury 
should be given to excite early salivation, and with this 
view, from one to three grains of calomel, every two, 
three, or four hours, will probably be the readiest form of 
exhibiting this valuable medicine, and particularly its in- 
fluence will be expedited by the previous bleedings and 
purgings. The local treatment, in addition to the leech- 
ing, &c, will consist in the application of warmth and 

22 



174 DISEASES OF THE EAR. 

moisture to the side of the head ; and in the careful avoid- 
ance of irritating the meatus by injections or otherwise. 
When the brain unfortunately becomes implicated, then 
the head must be shaved, and evaporating lotions freely 
applied, either warm or cold, as may be the more soothing 
to the patient's feelings. 

As when the disease arises idiopathically, not being 
preceded by chronic inflammation, nor by the milder 
affection, it generally happens that pus accumulating in 
the tympanal cavity, and becoming decomposed, more 
readily produces most important aggravation of the symp- 
toms, and is the frequent cause of inflammation extend- 
ing to the brain or its membranes, so does evacuation of 
the matter as soon as it is formed, become a circumstance 
of immense interest, and upon which, perhaps, the pa- 
tient's life may depend. In consequence of the urgency 
of the symptoms not abating, when suppuration of the 
tympanum has taken place, and from the probability of 
the rigors, when present, depending upon irritation of 
the brain, it is extremely difficult, and often impossible, 
for the nicest discrimination to decide accurately upon 
the presence or absence of such accumulation ; and its 
existence is frequently unknown, and, by the inexperi- 
enced, not even suspected, until it makes its way out in 
one of the three modes already alluded to, or until it has 
occasioned fatal disease of the sensorium. If, upon ex- 
amination, the membrana tympani appears opaque, and 
less than usually concave, and particularly if it has as- 
sumed a convexity indicating pressure from within ; if 
pain, and tenderness upon pressure, exist in the mastoid 
process, and especially if the integument covering it be 
tumefied and reddened, showing the probability of the 
inflammation, and perhaps also of suppuration having 
extended to its cells ; if air cannot be forced into the 
Eustachian tube by an expiratory effort during the clo- 
sure of the nose and mouth ; if, upon sounding the tube, 
(supposing the patient can bear the operation,) it is dis- 
covered to be imperforate and painful : and if the symp- 
toms have been progressive, notwithstanding the em- 
ploymentof active measures, the Surgeon will be justified 
in the endeavour to procure an exit for the pus supposed 



OTITIS INTERNA. 



175 



to have accumulated in the tympanal cavity, though that 
supposition may be incorrect. The most favourable mode 
of evacuation, when it can be procured, is through the 
Eustachian tube, as it may then be possible that the os- 
sicula may be saved, and with them the general functions 
of the tympanum. Itard, Andral, Roche, and others, 
prescribed for the removal of an obliteration of the tube 
in these cases, the forcible use of gargles variously medi- 
cated, — the application of tobacco fumes by means of a 
violent expiration, — the vapour of some emollient de- 
coction, or injections carefully introduced into the tube; 
these remedies as might be expected are rarely success- 
ful. It becomes then a question of moment to decide to 
what extent the Surgeon may apply force, by means of 
the Eustachian tube catheter, in order to break through 
the obstruction, as there exists considerable danger of in- 
creasing the inflammation, and even of rupturing the 
tube; in all cases the operation w T ill be productive of 
great pain. When the adhesion of the parietes is so com- 
plete as not to yield to moderate pressure, it will be pro- 
bable that the disorganization of the tympanum has pro- 
ceeded so far that the membrane will be ulcerated, and 
the bones eventually thrown out. The safer plan will, 
therefore, be, to discharge the pus through a perforation 
of the membrane; which practice will not admit of hesi- 
tation, when the membrane is protruded into the meatus. 
The Surgeon will more readily adopt this procedure, as 
it is the usual mode of evacuation, when the disease is left 
to the efforts of nature. An abscess formed over the 
mastoid process in consequence of the inflammation ex- 
tending through the bone, is of course to be immediately 
opened, and if it should communicate with the cells, the 
matter will be evacuated ; and when such communica- 
tion does not exist, if the bone be dead, as will generally 
be the case, an opening may be made through it, or an 
aperture too small for the purpose of allowing the pus 
freely to flow out may be enlarged. In these cases, the 
bone is ordinarily so much diseased as to be easily 
cut with a knife. When pus is lodged in the mastoid 
cells, having either been secreted there, or flowed into 
them from the tympanum, in consequence of the opening 



IJQ DISEASES OF THE EAR. 

of communication between these cavities being in the 
upper part, the fluid cannot pass into the tympanum, 
unless ulceration of the bone has previously occurred. 
Dr. Burne has therefore recommended, that in these cases 
the mastoid process should be perforated "by any fit in- 
strument, so as to form a free external communication 
with the cells, through which injections may be passed." 
The escape of the matter, through either channel, may be 
facilitated by injections of tepid bland fluids, when it is 
too thick or inspissated to flow out naturally. The after 
treatment of the abscess, and the caries of the bone, which 
is sometimes very extensive, must be conducted upon 
general principles ; the Surgeon, however, never losing 
sight of the probability of the disease in every stage being 
exasperated by any exciting cause, and which thus may 
endanger the brain. 

§ The milder form of acute Otitis Interna, — the inflam- 
mation of the mucus membrane of the middle Ear, with 
accumulation of mucus of Dr. Kramer, — the internal 
Catarrhal Otitis of M. Itard, — and variously named by 
other Authors, from the particular consequence of the 
disease which attracted their notice, does not in the greater 
number of instances long remain confined to the mucous 
membrane ; it extends gradually to the sub-mucous tis- 
sue, which becomes thickened, and the membrane itself 
more or less villous, assuming a chronic form, and afford- 
ing a chronic secretion. In very many cases, the milder 
affection becomes aggravated into a severer degree, 
upon the application of an exciting cause, or from an in- 
terruption to the general health, when suppuration, and 
ulceration of the tympanal membrane, with loss of some 
of the bones, will be produced. The disease may also be 
excited to the severer form, and terminate in the different 
modes we have just discussed. 

Sometimes without any evident cause, but generally 
in consequence of cold, or following mucous inflamma- 
tion of the fauces and tonsils, the patient experiences a 
dull heavy uncomfortable sensation in the Ear, attended 
with obtuseness in hearing ; the uneasy feelings vary, 
and may consist either of sharp pain, or of some degree 
of insensibility in the organ, but the diminution of func- 



OTITIS INTERNA. 



177 



tion is constant though differing in extent. Frequently 
there is irritation in the outer meatus, sometimes with a 
lessened secretion of wax ; and the patient now and then 
forces air through the Eustachian tube to remove some 
uneasiness, which effort produces pain. The sensations 
and hearing are influenced by circumstances of tempera- 
ture, of the atmosphere, of motion, — they are improved 
in w r arm dry weather, and when the excited action of the 
skin relieves that of the mucous membranes ; the symp- 
toms are much increased by any catarrhal affection, or 
interference with health from any cause, and then there 
is often a discharge of mucus from the Eustachian tube 
into the pharynx, more or less disagreeable, and which is 
expectorated with relief, (a) 



(a) " Predisposition to mucous engorgement of the middle 
ear is," according to Kramer, " most frequently seen in childhood 
and youth ; (I have scarcely ever met with it in old age ;) and 
also in scrofulous constitutions, where there is a disposition to 
mucous engorgements and catarrhal affections in general ; though 
even the strongest constitutions do not exclude the development 
of a local catarrh, confined to the middle ear. 

" The most frequent, or rather the only exciting cause, is the 
application of cold to the head and feet, the greater or less inten- 
sity of which determines the degree of development of the disease 
in particular individuals. 

" Frequently, only one ear is affected ; but if both are, not only 
the dulness of hearing, but also the difficulty of overcoming the 
disease, is always greater in one ear than in the other. 

" It is surprising when we consider the extreme narrowness of 
the Eustachian tube, and the frequency of catarrhal affections of 
the nares and pharynx, that mucous engorgement of the former 
canal should, on the whole, be rare. It is evidently of most fre- 
quent occurrence during moist autumns and springs, and in 
moist climates, e. g., in sea towns, from which places the greater 
part of those patients have come to me ; viz., from Hamburgh, 
Stettin, Swinemunde, Danzig, Memel, Custrin, &c. Under these 
circumstances, I cannot understand how the so-called English 
aurists, who must very frequently meet with the disease in a 
foggy city, like London, should have scarcely any notion of the 
proper diagnosis of the complaint, and still less of any rational 
mode of treatment." 

The prognosis is regarded by this author as altogether favour- 
able. 



178 DISEASES OF THE EAR. 

These symptoms frequently assume a chronic condi- 
tion, continuing for months or even years, with slight 
variations arising from causes more or less evident. At 
other times, and perhaps even more frequently, as the ex- 
perience of the Author of this treatise leads him to believe, 
notwithstanding the high authority of Kramer is opposed 
to that opinion, — the inflammation assumes a more 
acute form, giving rise to the corresponding symptoms of 
pain, extending in the directions already mentioned, • — 
frequently of giddiness, of deafness, of fever ; and in an 
indefinite time to a discharge of muco-purulent matter, 
at first tinged with blood, afterwards clearer, which hav- 
ing passed through the ulcerated membrana tympani 
escapes from the meatus, and which is often accompanied 
with the malleus, with or without the incus, and some- 
times also with the stapes. During this progress, which 
occasionally extends over many years, in consequence of 
becoming chronic, the disease may take on the severe 
form, and produce the sad consequences thereupon attend- 
ant ; and even after the pus and ossicula have escaped, 
a chronic discharge is frequently still continued. 

When the inflammation of the mucous membrane con- 
tinues without producing the above effects, an accumula- 
tion of mucus takes place in the cavity, giving rise to dul- 
ness of hearing, without producing complete deafness; 
this effect will not only be in proportion to the quantity 
contained in the cavity, but also in the ratio of its den- 
sity ; the mucus is likewise frequently mixed with films 
of fibrin, secreted by the turgid membrane, and which 
tend to clog the Eustachian tube, and thus confine the 
fluid, which appears to be proved by the circumstance of 
little white patches, as they are called by the patients, 
being spit out by hawking, when some mucus follows, 
with immediate improvement in hearing. Such mucous 
accumulation is a more frequent cause of hardness of 
hearing in persons habitually exposed to cold than is 
generally imagined, and which it is the more important 
should be well understood, as surgical art can often do 
much towards its removal. This disease is frequently 
accompanied by thickening of the lining membrane of the 
Eustachian tube, or by its temporary closure in conse- 



OTITIS INTERNA. 



179 



quence of the accumulation extending into that canal ; in 
which cases the diagnosis will be increased in difficulty. 
The membrana tympani is sometimes, though very rarely, 
so pressed upon internally, that its protrusion becomes 
evident upon examination by the meatus. 

The healthy condition of the auditory canal and of the 
tympanic membrane — the perfect function of the laby- 
rinth, as indicated by the perception of vibrations conveyed 
by the cranial or facial bones — the different sensations 
excited by the patient forcing air into the Eustachian 
tubes, the cracking in the healthy ear, the gurgling in 
that diseased, or the absence of all sensation if the tube 
be too far obliterated for the transmission of air — above 
all, the introduction of the Eustachian tube catheter (in 
the way presently to be described), readily removing what 
obstruction may have been formed : — the air forced 
through the catheter passing into the tympanum with 
rather an unusual difficulty — the mucous rdle produced 
by the air entering the cavity and mixing with the fluid, 
instead of striking somewhat loudly against the inner sur- 
face of the membrane, and which may be heard, as first 
shown by Laennec, with the stethoscope against the mas- 
toid process, or by the ear of the operator in contact with 
his patient's ; — the often partial escape of mucus into the 
throat upon the admission of air into the tympanic cavity ; 
and the more frequent and greater discharge upon the in- 
jection of warm water, with an immediate improvement 
in hearing, will satisfactorily prove the presence of mucus 
in the tympanum, which will be still more decided if the 
stylette or bougie passed through the catheter into the 
cavity be smeared with the mucus. The absence of the 
whole of these signs does not prove the contrary, as a 
stricture of the tube will render the investigation nuga- 
tory, (a) 

(a) Under the head of Diagnosis, M. Deleau points out the 
effects of douches of air on the middle ear in a state of disease. 
" The bruit de pluie, or sound of rain, produced by a moderate 
douche, is sometimes accompanied or followed by a slight pain 
and momentary increase of the dulness of hearing. It indicates 
an exaltation of sensibilitv — it is a commencement of inrlamma- 



180 



DISEASES OF THE EAR. 



The milder form of Otitis Interna becomes a common 
cause of stricture of the Eustachian tube, by exciting 
adhesive inflammation and thickening in the submucous 
tissue, which effect and its treatment are to be described 
under the head of Chronic Otitis. 

This form of disease of the Middle Ear is so common, 
that it becomes necessary to select cases for elucidation 
from the many that are reported, and are witnessed by 
the practitioner of surgery, rather than to describe all 
which come to his knowledge. Such being the case, 
the Author will confine his illustrations to one or two 
instances that have lately fallen under his cognizance. 

The Writer frequently examines the ears of Miss M., 
who is partially deaf; in whom the membrana tympani 
of the left ear is completely removed, and likewise the 
malleus and incus, the stapes being readily seen fixed in 



tion. This state can only be recognized and well appreciated 
when one is certain of having performed, without hesitation and 
fumbling, the operation of catheterism ; for it is easy to suppose 
that an awkward hand might, by throwing in the air with too 
great force, give rise to this morbid irritation in the ear : in the 
same way that too strong light would over-irritate the retina pre- 
disposed to inflammation by a delicate operation." 

" Sometimes, the catheter is engaged in the tube some lines 
only ; if we do not take precautions in withdrawing the stylette, 
the end of the catheter escapes into the pharynx. In this case the 
air which serves for the douche is dispersed in the pharynx ; if 
the catheter remains in the Eustachian tube, the air regurgitates 
immediately after having arrived at the extremity of the catheter, 
and makes the lips of the guttural orifice of the Eustachian tube 
vibrate. I call the sound which is heard, and which is more or 
less mucous, bruit da pavilion. When it is simple, it indicates 
a stricture or a complete obstruction, situated in the guttural half 
of the tube. When the obstacle to the introduction of air into 
the tympanum is near that cavity, we perceive, on applying our 
ear to that of the patient, the bruit de latrompe. If the douche 
is given at the pressure of about one atmosphere, both the bruit 
du pavilion and bruit de la trompe will be heard simultaneously. 
The bruit de la caisseis more or less mucous ; it is general or con- 
fined to one point of the tympanic wall. Little practice is re- 
quired to appreciate the different characters of it." pp. 133-134. 



OTITIS INTERNA. }gl 

its position above the promontory ; the wax is secreted 
in the outer Ear, in rather more than normal quantity, 
but healthy in quality. In the right Ear a small circu- 
lar portion of the membrane remains attached to the outer 
boundary of the cavity, the malleus is lost, and the incus 
is most distinctly seen united to the edge of the mastoid 
cells by its short crus, and by its long process to the 
stapes (Plate XIL, fig. 12). In the right auditory meatus 
small pustules occasionally form, which for a short time 
slightly increase the cophosis, This lady, last year being 
out of health, was much annoyed with ' noises in the 
head,' and her hearing was still further impaired during 
their continuance, which symptom doubtless arose from an 
erethitic affection of the auditory nerve. She can hear 
tolerably well with the right Ear, and to some extent 
with the left, though not so well as she otherwise might, 
in consequence of that ear being allowed to fall into dis- 
use from its greater imperfection than the other, and of 
the greater accumulation of wax. On requesting a his- 
tory of the early symptoms, the patient writes, that she 
1 recollects imperfect hearing at nine years old (she being 
now upwards of thirty) — discharge of blood from the 
left ear at that period, and several years afterwards — no 
recollection of pain or uneasiness attending it — took a 
violent cold from getting wet in an open carriage, and an 
abscess formed in that ear — the pain was so severe 
as to produce delirium — it was succeeded by giddiness 
so great as to prevent lying in bed without holding, at- 
tended with considerable fever — the giddiness con- 
tinued for many months — never heard but slightly with 
that ear afterwards — a discharge of matter from it for a 
great many months, but no pain or uneasiness, unless 
meddled with — nothing ever burst in the ear — no re- 
collection of any bone coming away — the deafness came 
on imperceptibly with the left ear, until an abscess, oc- 
casioned by cold, destroyed the hearing entirely — the 
throat was always sore at that time. She does not hear 
well with the right ear, the membrane being gone — 
never had any uneasiness in that ear until within the last 
twelve months.' 

23 



182 



DISEASES OF THE EAR. 



Amelia Rattenbury, aged fourteen, of a scrofulous 
habit, ' when four months old, laboured under violent 
pain and inflammation in the right ear, which lasted ten 
or twelve hours, when an abscess broke and discharged 
a teaspoonful of pus daily for three or four days. She 
has had occasional pain and discharge of purulent matter 
ever since.' Upon examination, it was found that the 
membrana tympani was completely lost, together with 
the malleus and incus, leaving the head of the stapes ex- 
posed to sight. She was unable to force air into the tym- 
panum through the Eustachian tube; the catheter rea- 
dily entered the orifice of the tube, but required a 
slight force for its complete introduction, when an ob- 
struction was removed, and she thought she could imme- 
diately hear on that side ; upon blowing with the mouth 
into the catheter, the air easily found its way through the 
external auditory canal. The other ear being healthy, 
it was not. likely that what improved hearing could be 
obtained, by the removal of the obstruction of the tube, 
would be much appreciated ; but as the girl thought her 
hearing was increased by passing the instrument, it was 
continued occasionally. In this instance the disease 
which disorganized the tympanum, has also occasioned a 
slight stricture of the tube/ 

Although when the Author first saw Amelia Ratten- 
bury, her disease was in a mild condition, yet its previous 
state would justify the case being classed with those of 
the severer form. 

The first case appears at the commencement to have 
been a catarrhal affection of the tympanum, exasperated 
into suppurative inflammation by cold ; and it affords a 
fair example of a very common progress which the dis- 
ease makes. Kramer has detailed several interesting 
cases of mucous accumulation in the tympanal cavity, pro- 
ducing deafness more or less complete, some of which 
could be temporarily relieved by the patients forcing air 
through the Eustachian tubes, which, displacing a por- 
tion of the mucus, thereby afforded the membrane of the 
tympanum an opportunity for increased oscillation. The 
Writer of this paper has to-day seen a case of engorge- 



OTITIS INTERNA. }g3 

ment of the tympanum complicated with diseases of the 
outer Ear, in which air was easily thrown in through 
the Eustachian tube, occasioning a gurgling noise, and 
attended for a few minutes with improved hearing. 

The accumulation of mucus in the tympanum may 
become chronic, continuing for many years, occasioning 
no other inconvenience than deafness, and sometimes an 
occasional discharge into the pharynx ; but still the dan- 
ger of acute disease being excited always exists. 

The observations that have been made relative to the 
milder form of Otitis Interna, are applicable to similar 
affections both of the mastoid cells and of the Eustachian 
tube, extensions as they are of the tympanal cavity. 

Probably, in every case of mucous accumulation, the 
mastoid cells are also more or less affected, and cer- 
tainly the effusion may take place there ; and if it pass 
at all into the tympanal cavity, it may be merely to an 
extent insufficient to materially influence the function. 
Such a case is also peculiarly predisposed to acute in- 
flammation, which may terminate in suppuration, and 
occasion a carious condition of the bone, often implicat- 
ing the tympanum in its course, and frequently leaving 
a very troublesome disagreeable sinus. 

The general effect of this inflammation upon the Eus- 
tachian tube, is the formation of a stricture, which must 
be noticed hereafter ; it may also occasion ulceration, 
either confined to the mucous surface, or, as dissection 
has proved, extending to the cartilage. This canal in 
which Otitis Interna frequently originates, is always more 
or less implicated in the progress of the affection ; and it 
is not at all uncommon for the disease to be confined to 
the tube, in which case it is most generally the conse- 
quence of an affection of the throat. The Author has 
seen many instances in which acute inflammation of ap- 
parently the mouth of the tube was excited by specific 
disease, as small-pox or scarlet fever, and which becom- 
ing chronic, had continued many years. 

The Treatment of the milder degree of Acute Internal 
Otitis is to be conducted on similar principles, and the 
remedies are to be the same, as for the more severe form*; 
the activity of procedure being proportionately less, corre- 
sponding to the milder form of the disease. Venesection 



184 DISEASES OF THE EAR. 

is too frequently neglected in this affection, for, though it 
ordinarily occurs in strumous subjects, yet by removing 
the acute symptoms as quickly as possible, the strength 
of the individual will be saved, rather than by allowing 
the disease to progress ; this important remedy must, 
however, be cautiously used ; leeching will be very requi- 
site, in almost all cases, with blisters, purgatives, fomen- 
tations, &c. The various accessions of inflammation, and 
its terminations, must be treated accordingly ; and espe- 
cially the Surgeon should ever keep in mind the great 
predisposition of the malady to assume the severest 
degree. 

With a view to lessen the mucous accumulation, atten- 
tion should be at first directed to the inflammatory condi- 
tion of the mucous membrane, which, inasmuch as the 
symptoms are often very lenient, will be best relieved by 
a milder course of therapeutics, such as leeching, and par- 
ticularly blistering, the neighbourhood of the ear and an- 
gle of the jaw ; improving the secretions, and especially 
that of the skin, the increased action of which influences 
so very importantly diseased conditions of the various 
mucous membranes ; fomentations, in the form of warm 
fluids or vapours, to the fauces, and as far as the patient 
can admit them without inconvenience, to the mouth of 
the Eustachian tube itself. When the inflammation has 
quite subsided, the tympanum may be washed out, and 
the mucus thus removed, by injections of warm water 
through the catheter introduced into the tube, or air may 
be forced in by the same means, and with the same in- 
tention ; these remedies must not be employed during the 
slightest inflammatory state, as they would be likely to 
increase the excitement ; unless, indeed, the Surgeon has 
reason to believe that the inflammation is maintained by 
the presence of the fluid. The mode of syringing the 
tympanum will be mentioned when the chronic affections 
of that cavity are considered. (a) 

(a) The author might have added very properly to these reme- 
dial means, the occasional use of emetics, at first to vomit and 
afterwards to procure nausea. Local stimulants to the mucous 
membrane of the fauces and pharynx, and, by continuous exten- 
sion, to the Eustachian tube and membrane of the middle ear, 



OTITIS INTERNA. ^5 



Section V. 

Acute Inflammation of the Labyrinth is still involved in 
a good deal of mystery, in consequence of the intricacy 

might be given with the same view, viz., an expulsion of the 
mucus of the middle ear through the tube and a removal of the 
chronic inflammation of the membrane of the tympanic cavity. 
Enlarged tonsils, especially chronic tonsillitis, will give rise to 
the disease in question. (See Yearsley on Deafness from Morbid 
Conditionof the Mucous Membranes ,8?c, of the Stomach, Throat, 
Ear, &c. ; also Stokes and Bell, Lect. VI., p. 86-SS, 2d edit.) 
After the use of the remedies already indicated, the hydriodate 
of potassa (iodide of potassium) will be had recourse to with 
manifest advantage, especially in those cases in which, associated 
with impeded hearing, are symptoms of depraved digestion and 
nutrition. 

In reference to the production of deafness by enlarged ton- 
sils, Deleau remarks, " that it is rather when these glands are 
subject to pass the state of acute inflammation, or when they are 
surrounded by a red and tumefied circle which invades the lateral 
walls of the pharynx, that hardness of hearing is perceived, or 
noises in the ear which the patients compare to the boiling of 
water, or to the rustling of leaves shaken by the wind. A con- 
dition still more serious which these glandular bodies take on, 
is their development from before backwards, so as to separate 
the pillars of the fauces. Hardness of hearing almost always ac- 
companies flattened glands which tend rather to sink into the 
flesh than to project into the throat." 

In order to prevent a return of catarrhal inflammation of the 
middle ear, Kramer directs that " the patient should persevere for 
many months, especially if he be of a lax, scrofulous constitution, 
in a mode of living which not only does not favour the disposi- 
tion to relapse, to colds, catarrhal affections, and mucous engorge- 
ments, but which is strongly opposed to these tendencies. Regu- 
lar active bodily exercise ; washing the neck and upper part of 
the body with cold water ; drinking freely of cold water ; early 
rising ; sleeping on a mattress and beneath the blankets ; a dry 
meagre diet, are among the principal things to be attended to, as 
I have already stated. 

"Those patients only, who are of strong constitution, and rather 
of a spare habit of body, and not the least disposed to mucous 
engorgements, may return to their ordinary mode of living after 
the removal of the local affection of the ear : in such persons re* 
lapses are rather rare." 



186 



DISEASES OF THE EAR. 



and minuteness of structure rendering it extremely diffi- 
cult to ascertain, upon dissection, organic alterations oc- 
casioned by disease ; and of the symptoms being obscured 
by those of other affections of the organ or of the brain ; 
and because Acute Otitis, perhaps, only exists in the 
labyrinth as an extension from the middle ear, or in con- 
nection with such affection. There can, however, exist 
but little doubt that the membrane which lines the bony 
labyrinth may be subject to inflammation, although at 
present post-mortem inspections throw but little light upon 
the subject ; and the cases that have been recorded of 
over-vascularity are certainly too definite to allow any 
correct conclusions to be deduced. No well authenticated 
cases are reported of inflammation of the membranous 
labyrinth ; yet it may be imagined that, as it certainly is 
organized as other structures, it must be influenced by 
similar diseases. Possibly the thickened condition of one 
or both of these membranes, which has been seen in old 
age, may sometimes be the result of inflammation, though 
generally it occurs as a change merely consequent upon 
the advanced period of life. Variations have been no- 
ticed in the Aqua Labyrinthi, which in some instances 
may be the result of inflammation ; thus the fluid has 
been observed by Dr. Haighton and Lentin to be turbid, 
and more dense than ordinary; by Pinel, Itard, and espe- 
cially by Ribes, it has been found in diminished quan- 
tity, so as to be insufficient to fill the canals ; whilst other 
writers have imagined it might be in excess. The ner- 
vous expansion itself has been seen to be inordinately vas-, 
cular, resembling somewhat the retina under a similar 
condition ; but then, as in the case of the retina, much 
dependence must not be placed upon this circumstance, 
as the small vessels may have become injected by blood 
during the dying state. The Auditory Nerve has fre- 
quently been seen disorganized, the nervous matter being 
removed, and the neurilema occupied by fluid ; it has been 
found much harder than natural, as well as much softer, 
and enlarged ; and, again, less than half its size : such 
variations have been recorded by Haightonj Mondini, 
Sylvius, and others ; and it is probable that sometimes 
these conditions may occur as different effects of inflam- 



OTITIS INTERNA. 



187 



mation; though it is certain that in some of the reported 
cases the defects were congenital ; in others the age of the 
individuals was great, and the deafness but of few years 
standing ; yet in a few it appears that the consequent co- 
phosis came on during middle life, and was, therefore, pro- 
bably occasioned by acute lesion of the nerve. The ex- 
istence of acute inflammation of the nervous expansion is 
rendered probable by its analogy in structure and func- 
tion to the retina, the inflammation of w T hich is well 
known to be one cause of Amaurosis ; and as extreme in- 
tolerance of light, and darting pains through the head, are 
the chief signs of this affection, so may those cases of in- 
tolerance of sound, and similar pains through the brain, 
with a general state of excitement, be attributable to a 
similar condition of the nervous membrane of the laby- 
rinth. The Author of this essay is, however, far from 
wishing it to be understood that he thinks every altered 
function of a nerve, or its expansion, is the effect of recog- 
nizable inflammatory action, as every day's experience 
clearly proves the contrary. 

As so very little is practically known of Otitis of the 
labyrinth, it would be misplaced to describe at any length 
what may be the supposed symptoms of such a state, 
particularly as they may be collected from what must 
necessarily be observed when we dwell for a short time 
upon nervous deafness. It may, however, be noticed, 
that the leading signs of such affection will be a Tinni- 
tus Aurium ; an intolerance of sounds, and especially of 
loud noises ; pains in the head, occasionally shooting into 
the tympanum; general exoitement,in some cases amount- 
ing to fever. The treatment in such instances must be 
antiphlogistic, combined with mild sedatives, notwith- 
standing it is most likely to occur in debilitated persons, 
and in those whose irritability is great. 

Dr. Kramer admits that the labyrinth may be subject 
to inflammation ; yet, as this is in some degree doubtful, 
he recognizes only the disease of the nervous expansion, 
nervous deafness, which he describes as being of two kinds, 
erethitic or nervous deafness with excitement, and torpid 
nervous deafness : the first may be considered as consti- 
tuting the acute, and the latter the chronic form. This 



]_gg CHRONIC DISEASES OF THE EAR. 

arrangement is probably the best that has been yet ad- 
vanced, and although the erethitic form may sometimes 
depend upon inflammatory action, yet as it often is of 
long standing, and assumes more or less a chronic cha- 
racter, it will be perhaps better to treat of the two states, 
under the general head of Chronic Diseases. 



CHAPTER II. 

ON THE CHRONIC DISEASES OF THE EAR. 

Diseases of the Ear are much more frequently wit- 
nessed in the chronic form than in the acute, being either 
terminations of acute or subacute affections, or originat- 
ing in the chronic degree. The great majority of cases 
of deafness result from this form of disease, which in 
some instances continues during life, producing little 
more inconvenience than what may arise from the co- 
phosis more or less complete ; whilst in others it gradu- 
ally passes to the structures in the vicinity of its original 
locality, producing the most extensive disorganization. 
All cases of chronic disease, particularly of the middle 
Ear, are predisposed to excitement into the acute form 
upon the application of suitable local stimulants, or in 
consequence of a general affection. 

It is purposed, in treating of the chronic diseases, as 
being more convenient, though not strictly in order, to 
make some observations upon the accidents and injuries 
to which the different parts of the organ may be liable. 

This form of disease of the Ear has been very variously 
named, and often in consequence of a particular symp- 
tom. Dr. Kramer has arranged these affections more 
philosophically than other Authors, according to the 
structures affected, as he has endeavoured also to classify 
the acute diseases ; this mode of considering them, 
although decidedly the best when medical knowledge is 
so perfect as to enable it to be accomplished correctly, is 



EXTERNAL CHRONIC OTITIS. 



189 



not free from objection, inasmuch as several structures 
may be affected at the same time, the diseased action 
may pass from one tissue to anotrier, and in many cases 
the most accurate observation will fail in making the nice 
discrimination such an arrangement seems to require. 
And thus if the practice is to be directed by such divi- 
sion, as the symptoms of the supposed different affections 
run into each other, the Surgeon relying too much upon 
his theory, may be led into the adoption of unsuccessful 
treatment. Itard, and after him Andral, and many other 
authorities, have used the term Otorrhcea almost synony- 
mously with chronic Otitis, thus naming the different 
diseases from a symptom which is very common to them 
all, namely, a discharge of matter from the meatus ; and 
as this discharge may be either mucus or pus, so the 
Otorrhsea is divided into Catarrhal and Purulent. This 
arrangement, although not so pathological as Kramer's, 
is more applicable ; and if the practitioner regards it in 
its true light as expressing only a symptom, and takes 
care to ascertain its cause, it will also become even more 
practical. But as indeed many chronic affections of the 
Ear exist, in which there is no discharge, so the term 
Otorrhea is inapplicable as a general synonym. In 
treating this part of the subject, therefore, the name of 
Otitis Chronica will be adopted, which term has been 
used in a similar manner by Roche. Mr. Curtis appears 
to designate Otorrhsea to be a puriform discharge from 
the tympanum ; whereas the discharge is quite as fre- 
quently the product of a diseased action of the dermal 
membrane of the meatus auditorius. 

Following the arrangement adopted in considering 
Acute Otitis, the chronic disease as it occurs in the dif- 
ferent divisions of the Ear, will be discussed. 



Section I. 

EXTERNAL CHRONIC OTITIS. 

This affection must also be arranged under two heads, 
that of the Auricle, and that of the Auditory Meatus. 

24 



1 9Q CHRONIC DISEASES OF THE EAK. 

Chronic Inflammation of the Auricle arises from the 
common causes which excite disease in other parts of the 
body ; but as the auricle is not a very irritable structure, 
in consequence of the supply of nerves being proportion- 
ally less than that of blood-vessels, — which is a very 
beneficial arrangement, having reference to the function 
and exposure of this structure ; — these causes are not so 
frequently in operation as might otherwise be expected 
from its exposed situation ; and, therefore, most of the dis- 
eases of the auricle extend from the surrounding parts, or 
are produced by direct injury. Cold, however, does excite 
disease in this part, and even, as is well known, if the tem- 
perature be exceedingly low this structure may be frost- 
bitten, and may thus be immediately deprived of its vi- 
tality, although it more frequently happens that the part 
is destroyed by the subsequent reaction. Chronic in- 
flammation is also excited by pressure from lying upon 
the side during the existence of fever, or other general 
affection, which predisposes to local disease. Such a 
cause is not at all uncommon ; and Boyer mentions the 
case of a "medical student, compelled by an ulcer on the 
sacrum to lie for a long time on his side, which occasion- 
ing pressure on his ear caused a slough of the anti-helix, 
and after the separation of the dead part, an aperture, 
large enough to receive the end of the little finger was 
left in the pinna." 

The foolish practice of ear-boring in irritable subjects 
is a frequent cause of chronic enlargement of the lobus. 
Portal has seen this part an inch thick, and notices the 
prodigious effect produced in a woman by wearing heavy 
ear-rings, which kept up a constant irritation. Chronic 
disease of this part of the organ is, however, much more 
frequently the effect of erysipelas, than of other acute af- 
fections. But the disease, when arising in the chronic 
form, is generally a cutaneous affection, which may com- 
mence here, or spread to it from the surrounding parts ; 
hence, it is very common to meet with Erythema of the 
Auricle, with Herpes, Porrigo, Lepra, Crusta Lactea, 
Lichen, in fact with all the chronic affections to which 
the cutaneous system is prone, and which sometimes in- 
duce a thickened and enlarged state, continuing after the 



EXTERNAL CHRONIC OTITIS. 



191 



original disease has subsided. Such diseases are exceed- 
ingly common in children during dentition, and in them 
they often are pustular, or vesicular. It is very usual, 
indeed, for these affections of the auricle to accompany 
strumous ophthalmia, depending upon the same cause, 
and to be alike removed by means of general remedies, 
assisted by local treatment. These various forms of 
chronic inflammation are evidently prone to extend to the 
auditory canal, and thus they become frequent causes of 
diseased action in that tube. Encysted and steatomatous 
tumours, likewise form in the cellular membrane of the 
auricle, requiring the treatment they receive when in 
other parts of the body. The Author occasionally sees a 
lad, who has a small encysted tumour in the concha, which 
as it does not produce inconvenience is allowed to remain, 
but could be extirpated without trouble. Mr. Travers 
removed "the upper third of the external ear, which was 
the exclusive seat of an indurated sore, having every cha- 
racter of cancer." 

The symptoms of common chronic inflammation do not 
differ from those of the same affection occurring in other 
organs ; the disease is slow in its progress, — pain is but 
slight, being rather a sensation of itching than actual suf- 
fering, — redness not uniform, nor very bright, — heat 
moderately increased, — tumefaction not at first great, 
but gradually augmenting. Sometimes it terminates in 
an inordinate growth, and often in more or less general 
induration, occasioned by adhesive deposit into the cellu- 
lar tissue. 

The treatment must be conducted on the usual allopa- 
thic principles; and as it often happens that the local af- 
fection is maintained by general derangement of health, 
an improvement of the state of the constitution will re- 
quire the first attention. The ulcer, or hardened and 
thickened condition which may result, will require the 
ordinary applications; in the latter state Iodine will often 
be found a very useful local remedy. 

§> Chronic Inflammation of the Meatus Auditorius Ez- 
ternus, presents a variety of symptoms, depending upon 
the cause, and the structures involved in the disease. The 



1Q2 CHRONIC DISEASES OF THE EAR. 

chronic affection of this tube is a frequent cause of Otor- 
rhsea giving rise to dulness of hearing, yet it is by no 
means the only one. It is much to be regretted that 
either in consequence of the due investigation of the tym- 
panum being attended with some degree of difficulty, or 
from the general inattention which has prevailed as re- 
gards aural surgery, practitioners have for a long while 
directed their applications solely to the external tube ; and 
it is much to be feared have, by their too often empirical 
treatment, increased the disease, and expedited its exten- 
sion onwards to the tympanal membrane and cavity. As 
these diseases are somewhat various, it may render the 
history of them clearer and more simple, to describe them 
under different sections, and as far as the Author's expe- 
rience will permit, in the order in which they more fre- 
quently are met with in practice. 

1. Ery thematic chronic disease of the meatus. The 
Writer uses this term, perhaps incorrectly, to denote a 
frequent affection, described by Roche under the name 
of t Otite Chronique Seche. In this disease the general 
health is usually impaired, though ordinarily without any 
serious malady being apparent, — there is uneasiness in 
the auditory canal, — sometimes slight pain, — returning 
at intervals, with an itching dry sensation, — occasion- 
ally attended by heat, — there is also difficulty of hearing, 
and not unfrequently some tinnitus aurium ; but in ge- 
neral no further inconvenience is experienced than what 
arises from the deafness, and from the uncomfortable 
sensations occurring in the canal. The tube upon in- 
spection is found to be unusually dry, and if the wax be 
formed at all, it is in very small quantity ; but most fre- 
quently there is a vitiated secretion of a white or yellow- 
ish scaly matter, which lines the tube more or less ex- 
tensively, generally formed into small patches, though 
sometimes occupying the whole length of the canal ; this 
morbid matter is easily separated from the surface, but 
usually remains in the tube unless artificially removed, 
This secretion is the product of the ceruminous follicles, 
and is probably the wax mixed with abnormal constitu- 
ents, quickly converted by evaporation into this peculiar 
matter. The mucous, or dermal lining of the tube, pre- 



EXTERNAL CHRONIC OTITIS. 



193 



sents a rosy appearance in certain points, which in more 
extensive cases occupies its entire length. A similar 
vitiated secretion, solidified byinspissation,hasbeen found 
covering the surface of the tympanal membrane, either 
secreted from its outer face, or extending over it from the 
canal; the former is the more probable supposition, as 
this deposit has been occasionally seen upon the mem- 
brane, when the accumulation has been so slight in the 
tube as hardly to justify the belief that it could be de- 
rived from that source. 

This abnormal product is a very common affection, 
and becomes the cause of dulness of hearing more fre- 
quently than is perhaps imagined ; and although it gener- 
ally exists without any other affection of the aural organ, 
yet it not unfrequently accompanies a deficient sensi- 
bility of the acoustic nerve. As such a secretion is very 
frequently removed from the meatus of young subjects 
which are submitted to anatomical dissection, it is very 
likely that it may arise from the diminished energy of 
the dermal membrane during the illness which terminated 
fatally ; and it is also further probable that in many other 
instances lessened powers of secretion may produce this 
mal-constituted matter instead of healthy cerumen, and 
that its presence may be the cause of the slight inflam- 
mation noticed. Though this may be a probable cause, 
no doubt exists in the Writer's mind that it is usually 
the product of a chronic inflammation of a peculiar or 
erythematic modification. 

The author remembers a lady who was in delicate 
health, and had borne several children within a short 
period, w r ho suffered considerable annoyance for many 
years from the affection under notice ; it was much in- 
creased by the slightest general excitement, yet gave rise 
to but little alteration in hearing. The disease was bene- 
fited by such remedies as amended the health, and by 
the application of astringents. 

A child who had been deaf for some months, heard 
almost perfectly well, immediately upon the Surgeon 
removing a thick, white, toughish scaly matter from the 
surface of the membrane of the tympanum. 

The late Mr. Earle has detailed several cases of this 



|94 CHRONIC DISEASES OF THE EAR. 

affection in the tenth volume of the Medico- Ghirurgical 
Transactions, and as one is an aggravated example, the 
heads of the history may be related : — 

"In 1816, Mr. F., an ensign, gave this account of his 
Ears ; from childhood he had been occasionally liable to 
attacks of inflammation in the external Ear, accompanied 
with heat, excoriation, and a copious thin discharge from 
the passage, which affected his hearing, more or less, for 
several weeks, but left no considerable permanent deaf- 
ness behind. About ten months before his application, 
he had been exposed to damp, and, in consequence, suf- 
fered a severe renewal of the same disease, which so 
nearly deprived him of the power of hearing, as to oblige 
him to leave his regiment, in pursuit of further advice, 
with an understanding, that unless he could obtain some 
relief, it would be necessary for him to quit the service, 
as he was quite incapacitated from active duty, by not 
being able to hear the word of command. On examina- 
tion, I found the meatus of either Ear much narrowed 
in its calibre, by the thickening of the surrounding parts, 
and especially the great increased density of the cuticle, 
which had a very white appearance, and was moistened 
by a thin discharge, resembling runnet-whey, that depo- 
sited a substance not unlike small portions of curd. On 
washing this away, and dilating the passage, there was 
not the slightest appearance of cerumen ; but the same 
white thickened cuticle appeared to extend as far as the 
eye could reach. The sense of hearing was nearly lost, 
but a watch applied to the teeth or forehead was dis- 
tinctly audible. On injecting water, a dull obtuse sound 
was produced, as if some dense medium were interposed ; 
and by passing a probe to the bottom of the meatus, a 
sensation to my touch was conveyed, different from that 
which would have been produced by the contact of a 
healthy membrane ; whilst at the same time it did not 
cause the usual painful sensation. These circumstances 
led me to imagine that it was possible that the deafness 
depended either on a thickened state of the cuticle re- 
flected over the mernbrana tympani, similar to that which 
lined the meatus, or on some morbid secretion existing 



EXTERNAL CHRONIC OTITIS. 



195 



between this cuticular layer and the membrane. To 
effect the removal of this cuticular lining, I had recourse 
to the nitrate of silver ; and threw in, with a silver syringe, 
a very strong solution, which completely blackened the 
epidermis of the meatus. In a few days, upon syringing 
with warm water for a considerable time each day, the 
exfoliations were detached, in small portions at first, but 
subsequently in longer pieces, one of which, from its 
form, was very evidently the reflected layer which had 
covered the membrana tympani. The next syringeful 
occasioned a very distressing sensation and loud sound. 
His hearing from this time was greatly improved, but 
still rather confused. The other Ear was treated in the 
same way with similar success. In a few days the hear- 
ing was very nearly restored. After the separation of 
the cuticle, the treatment consisted in the application of 
Ungt. Hydrarg. Nitratis, dr. iv., Cerati Cetacei, dr. iij., 
Olei Olivce, dr. i. ; which was introduced night and 
morning, with a view to stimulate the ceruminous glands ; 
blisters were used with the same view. Soon afterwards 
he returned to his regiment, and continued quite well ; 
the healthy secretion having returned." 

The author has quoted this case at greater length than 
he intended, for although Mr. Earle describes the mor- 
bid product, as consisting of thickened cuticle, and seems 
to imagine that it resembles the covering found on the 
feet from pressure, — he feels satisfied it is an excellent, 
though aggravated example of the erythematic chronic 
inflammation long neglected. 

In the same paper Mr. Earle alludes to two cases, in 
which this white scaly matter was mixed with cerumen, 
and nearly closed the meatus. One was relieved by the 
improvement of the health, and the use of a combination 
of the ointments of zinc and nitrate of mercury. The 
other was neglected. 

The treatment of this form of chronic external otitis, 
will not materially differ from that of other varieties of 
the affection. The amendment of the general health is 
of the first importance, and this is ordinarily best effect- 
ed by mild alteratives, and the remedies usually denomi- 



196 



CHRONIC DISEASES OF THE EAR. 



nated tonics, of which sarsaparilla has been held in great 
estimation; change of air; warm sea-bathing, &c, are 
all beneficial adjuncts. When the actions of the vege- 
tative organs, among which the secretions form so im- 
portant a class, are improved, local remedies will in most 
instances be attended with happy results, and the more so 
in proportion to the early treatment of the case. It will 
rarely happen that the symptoms of inflammation are 
sufficiently high to justify the use of leeches; but blis- 
ters behind the auricle possess the beneficial advantage 
of derivatives, when the action of the membrane of the 
meatus is increased ; and of excitants when the action is 
diminished. Experience teaches us, that the best appli- 
cations are astringents, and of these the nitrate of silver 
in solution is usually the most efficacious, in strength 
varying from two grains, even to a scruple or more, to an 
ounce of distilled water; the sulphate or acetate of zinc, 
the salts of copper, and of alum, are very valuable appli- 
cations. Previously to their use, it is requisite to well 
syringe the meatus, and to remove as much of the inspis- 
sated matter as possible. The strength of the solution 
should accord with the excitability of the meatus, and, 
indeed, also with that of the individual ; and particularly 
with the extent of morbid secretion. In some cases of 
extreme thickness of deposit, the nitrate of silver may be 
advantageously applied in substance, by cautiously intro- 
ducing the stick into the canal, as the artificial covering 
will protect the lining membrane from injury. Stimu- 
lating ointments are also found of marked benefit, as those 
of the nitrate of mercury, of the oxyde of zinc, &c, suffi- 
ciently diluted, introduced twice a day upon a camel's 
hair pencil-brush, as far into the meatus as the disease 
extends, and even, if requisite, upon the surface of the 
membrane itself. 

2. Chronic Inflammation of the Dermal Membrane, 
with inordinate Secretion: this is the "Humid Chronic 
External Otitis" of Roche; the " Mucous or Catarrhal 
Otorrhsea" of Itard and Andral : as the latter denomina- 
tion includes a very important symptom, it may be con- 
sidered as an appropriate term. This affection is very 
common, and is that which, without doubt, most fre- 



EXTERNAL CHRONIC OTITIS. ^97 

quently occurs in children ; in whom it is often excited 
by the irritation produced by dentition. The disease 
may be the consequence of acute inflammation ; and very 
frequently is the result of an injury occasioned by a fo- 
reign body, arising either during its presence, or after its 
removal. The same causes that produce acute inflam- 
mation, will likewise occasion at once the chronic form ; 
and the spreading of exanthematous diseases must be 
reckoned as one of the most frequent excitants. It is also 
described by Itard in particular, as well as by other wri- 
ters, as arising from metastasis, as from gout, gonorrhoea, 
mucous ophthalmia, &c. Scrofulous individuals are par- 
ticularly predisposed to this form of disease ; which is the 
reason, in addition to the accumulation of dirt in the mea- 
tus, that it so very constantly presents itself in the poor 
children of crowded localities. 

The symptoms are generally very mild, and hence the 
affection is so often neglected ; there is some uneasiness 
in the Ear, rarely amounting to pain, and after the disease 
has existed for a few weeks even that unpleasantness sub- 
sides : the part appears to be hardly increased in temper- 
ature. The hearing is a little diminished, more particu- 
larly at the commencement of the malady ; but if the tube 
be not contracted by morbid vegetations, this effect is 
often but slight. The discharge, which is generally pro- 
fuse, is at first smaller in quantity than subsequently ; 
variation in this respect occurs from time to time, usually 
in consequence of an apparent increase of inflammation, 
but often without any evident cause. The matter likewise 
changes its character, presenting at differ times various 
shades of colour, odour, and consistence ; at one time 
being serous, at another mucous, and then puriform, or 
these different appearances may be variously combined ; 
occasionally little white patches are mixed with the fluid, 
which frequently adhere slightly to the surfaces ; these 
incrustations occasionally consist of fibrin, though more 
generally of inspissated mucus. The variations indicate 
the varying degrees of inflammatory action at the different 
periods. 

The lining membrane of the auditory canal is some- 
times but little altered from its natural condition ; gene- 

25 



J9g CHRONIC DISEASES OF THE EAR. 

rally, however, presenting the appearance of chronic in- 
flammation, it is reddened, irregularly tumefied, and, 
when the disease has existed for some time, it even be- 
comes spongy or rather villous ; the surface is often co- 
vered with numerous little granulations or vegetations, 
varying in size and number, and of a reddish colour, from 
which the matter appears to be secreted ; some of these 
are new growths, though probably the bulk of them 
are enlarged ceruminous glands. It not unfrequently 
happens that Fungi or Polypi are consequences of this 
affection, which, partially or completely obliterating the 
tube, occasion more or less deafness : sometimes such 
formations are attached to the whole circumference, but 
in general to one face only of the canal. Now and then 
the disease gives rise to chronic ulcers, which may ex- 
tend to the cartilage, or even through it, though they are 
usually confined to the thickened mucous membrane. 
This affection, which often continues for months, some- 
times even for years, and occasionally during the person's 
life, is for the most part unconnected with disease of the 
tympanum, although such complication is by no means 
rare, as this important cavity is liable to be involved in 
consequence either of the extension of the chronic inflam- 
mation, or of the matter, not being freely discharged, and 
lying in contact with the membrana tympani, exciting in 
that structure chronic disease, which generally leads to 
ulceration. 

Acute Inflammation, taking the course already de- 
scribed, may supervene upon the chronic condition. The 
frequent occurrence of this disease renders it unnecessary 
to report any cases. 

The Treatment is that which is adapted to other 
chronic affections, and should be conducted in the mode 
already described when speaking of the Erythematic in- 
flammation. The improvement of the general health is 
of the first moment. The cause of the disease should be 
sought for, and if possible removed; thus the division 
of the gum, if dentition be the excitement, will be abso- 
lutely required ; if the presence of a foreign body in the 
meatus be suspected, the canal should be carefully ex- 
amined, with a view to the removal of the irritant ; the 



EXTERNAL CHRONIC OTITIS. 299 

neglect of this precaution has allowed a disease to become 
persistent, which otherwise might have been removed in 
a few hours. Leeches will only be requisite when the com- 
plaint is exasperated, which may be the case in conse- 
quence of a too stimulating regimen : blisters and other 
counter-irritants, as issues and setons, are most valuable 
remedies : as local applications, the astringent lotions are 
chiefly to be depended upon ; and of these the solutions of 
alum, of zinc, of lead, and of the nifrate of silver, in the 
proportion of from one to three or five grains to an ounce 
of distilled water, must hold the first rank in the scale of 
utility. Kramer recommends, in the spongy condition 
of the chronically diseased meatus, tents of fine soft lint 
dipped in a solution of the acetate of lead, introduced 
into the tube, the pressure of which is eminently useful. 
It has been noticed that the discharge sometimes sub- 
sides upon the occurrence of disease in another organ ; 
as for example, the enlargement of the neighbouring ab- 
sorbent glands, inflammation of the eyes, or skin, or even 
it is said of the testicles ; a similar result may be the 
consequence of an affection of the brain, which affection 
may indeed be consecutive upon the Otorrhsea. It is of 
the highest importance that the attention of practitioners 
should be directed to the fact, that serious mischief has 
not unfrequently been induced in the brain by the inju- 
dicious employment of irritating injections : these appli- 
cations, at the same time that they arrest the secretion, 
may excite so much inflammation that it readily spreads 
to the surrounding predisposed structures ; the mere ces^ 
sation of the discharge even may produce a vicarious 
increased action in the cerebral membranes, without an 
accession of Otitis. Much caution is therefore required 
in the administration of local astringents ; and it is better 
first to employ the mildest, as even warm water or milk, 
and gradually to use the more powerful according to the 
effects produced. Itard seems to carry his fears rather 
to an extreme in these cases ; yet, when the tympanal 
cavity is involved, his caution is quite justifiable. This 
aural pathologist, to whom mankind are so much indebted, 
guards us against the use of oily injections, as they are 
apt to become rancid in the ear, and to block up the dis- 



200 CHRONIC DISEASES OF THE EAR. 

charge ; he mentions a case of a child, in whom Otor- 
rhea was suddenly suppressed by an injection of linseed 
oil, and who was seized with convulsions, which quickly 
terminated fatally : in all probability, in this instance, 
the cavity of the tympanum was diseased, and in part 
furnishing the secretion. It has long been a fashion in 
this country to apply ox-gall mixed with oil of almonds, 
to the chronically secreting meatus, as a stimulant and 
lubricant combined. The tincture of castor is another 
remedy which has been vaunted, perhaps without any 
just grounds ; but the empirical employment of such ap- 
plications urgently calls for condemnation, especially 
when, as in such circumstances so frequently happens, 
the condition of the tympanum is altogether overlooked 
by the prescriber. It will be necessary for the Surgeon 
to ascertain if the escape of the matter be prevented by 
an inspissated substance, or perhaps by bone, if exfolia- 
tion be occurring, in order to remove the obstruction. 

3. Polypus, Fungus, or Vegetation of the Auditory Canal 
is an exceedingly common occurrence. These terms are 
very frequently used synonymously ; but probably it 
would further pathological distinctions if they were better 
defined. The Term Polypus (though its etymology 
means many footed) is ordinarily applied to a growth 
from a particular spot of a mucous membrane, the rest of 
the membrane being healthy, or at all events not impli- 
cated in that growth. This morbid production has 
usually one pedicle, but there may be several such attach- 
ments : its vascularity varies, occasionally a single artery 
runs down the centre, while in other cases the whole poly- 
pus resembles a congeries of blood-vessels. Fungus is 
usually intended to imply a diseased growth, arising from 
a membrane more extensively disorganized and fre- 
quently proceeding from an ulcer or a sinus ; it consists 
of a mass of exuberant granulations, always soft and vas- 
cular, but, as there is usually a want of power in the cir- 
culation, the colour is generally of a palish-red hue. The 
fungus, unlike the polypus, is not uniform in its shape, 
but irregular, both as regards its extent of attachment to 
the diseased membrane, and as respects the division of 
its loose extremity into lobules. There is always a dis- 



EXTERNAL CHRONIC OTITIS. 



201 



charge of matter, either mucous, purulent, or muco- 
purulent. The term Vegetation is most frequently ap- 
plied to numerous little diseased growths from a more or 
less extensive surface of a mucous membrane ; they are 
sometimes soft and fungoid, with narrow attachments ; 
at other times firm, and conical ; the degree of vascular- 
ity varies; and the vessels always secrete a fluid, though 
not so copiously as in the fungus. This species of mor- 
bid excrescence appears to consist in some instances of 
enlarged follicles, in others of organized deposits in the 
membrane and the sub-mucous tissue, and occasionally of 
little fungi. 

Such are the different appearances these growths as- 
sume in the external ear in particular, as well as in other 
parts of the body. The Polypus of the meatus is generally 
red and vascular, and if secreting at all, it is in a very 
limited degree ; it often arises without evident cause, yet 
is frequently the consequence of some local irritant, as a 
foreign body, or injury of the lining membrane by the ear- 
picker. The body, usually attached by a single root, is 
oval or round, and generally regular. It often acquires 
a moderate size before the patient is aware of its existence, 
and his attention is at length drawn to it by a slight and 
increasing difficulty of hearing, depending upon the ob- 
struction produced by the polypus — by a little uneasi- 
ness occasioned by its pressure — by a discharge from 
the ear in consequence of a cold — and by the bleeding, 
which arises when the finger or other substance is intro- 
duced into the canal. When large enough to occupy 
the whole calibre of the meatus, the tumour occasions 
deafness, the cause of which is, of course, immediately 
apparent upon examining the ear. A polypus may pro- 
ceed from any part of the auditory tube, and likewise from 
the surface of the membrana tympani. The accompany- 
ing drawing (Plate XIII.) is a faithful representation of 
Mr. Martin's ear, and affords an excellent example of the 
usual character of this growth ; the polypus is attached 
to the anterior wall of the canal by a single pedicle, and 
might be most easily removed, by which, no doubt, his 
deafness would be relieved. 

The polypus does not always present the highly vas- 



202 CHRONIC DISEASES OF THE EAR. 

cular appearance, but when, as in the following case, it 
consists of a very considerable elongation of fungoid gra- 
nulations, the enlarged extremity is often supplied with 
blood only sufficient to maintain its existence ; and even 
that sometimes fails when the growth of the tumour is still 
more extensive in proportion to its nourishment. 

Mr. G. W., aged seventeen. — At two years old was 
affected with scarlet fever, in consequence of which dis- 
ease his life was despaired of for a month or six weeks, 
and he continued indisposed for three months, during 
which time the glands at the angle of the jaw (tonsils ?) 
suppurated, and were lanced about two months after the 
attack. During the progress of the disease he became 
deaf, and had a copious discharge from both ears, which 
has continued ever since from the right ear, and until 
within two years from the left. About two years ago a 
tumour was noticed in the right ear, which has slightly 
enlarged. A similar growth occurred in the left ear, but 
smaller, ' which burst and went away.' 

August 15th, 1838. — Upon inspection of the right ear, 
the Author found a polypus, nearly colourless, with a few 
minute vessels ramifying in it, the head about half a 
square inch in extent, projecting beyond the meatus, and 
attached to the parietes of the canal by a narrow and long 
pedicle (which it is possible might have reached back- 
wards to the membrana tympani). Upon moving the 
body to one side, very vascular fungi were seen to occupy 
the whole calibre of the meatus, from the middle of the 
canal backwards, and which surrounded the attachment 
of the polypus. A very copious and offensive discharge 
was furnished by these fungi. Upon passing the probe in- 
wards beyond these growths, it appeared to strike against 
the bony wall of the tympanum ; the probability, there- 
fore, is great, that they proceed, in part at least, from that 
cavity. The meatus of the left ear contained a large 
quantity of inspissated muco-purulent matter, upon the 
removal of which it was seen that fleshy vascular vegeta- 
tions occupied the bottom of the meatus, completely ob- 
literating the membrane ; the condition of which it is at 
present impossible to ascertain. Both the Eustachian 



EXTERNAL CHRONIC OTITIS. 



203 



tubes were healthy. The patient is deaf to a degree to 
interfere with his occupations, but can hear a little better 
on the left side than on the right. 

The Author extirpated the polypus with the scissors, 
as far as the fungus, and has since touched the diseased 
growths with the lunar caustic every day. They are 
diminishing in size, and the discharge is much lessened, 
with a corresponding improvement in hearing. 

The treatment consists in removing the body ; and 
when it is attached to the wall of the meatus, and can be 
reached by the knife or scissors, excision will be the rea- 
diest and most efficacious mode of extirpation ; the 
hemorrhage, may be arrested, if necessary, by the nitrate 
of silver, any mineral acid, or the muriate of barytes in- 
troduced on a probe, or indeed by any approved styptic, 
or by pressure carefully made with layers of lint, or a 
piece of sponge ; and the same remedies occasionally used 
will prevent its recurrence. A ligature may be also 
sometimes, though generally with difficulty, passed round 
the morbid growth ; if the ligature be of silk it may be 
applied with the aid of an eye-probe, or if it be silver 
wire conducted by means of a small double canula, and 
tightened from day to day, until the tumour drops off. 
If the whole attachment of the polypus cannot be encom- 
passed, the judicious Surgeon not knowing its extent will 
proceed with great caution in the removal, as it is probable 
that the tympanal membrane may be implicated in the dis- 
ease. The polypus may also be twisted off, with a pair 
of well grasping forceps, either partially or entirely ; if 
the former takes place the operation must be repeated, 
and escharotics applied to the lacerated surface. These 
modes of treatment are not free from danger, when the 
membrane of the tympanum is diseased, and especially 
when the cavity is exposed ; as the predisposition to in- 
flammation is then much increased, and the tumour may 
proceed from the tympanal lining. A polypus growing 
from the surface of the membrana tympani will not admit 
of removal, unless it projects so far outwards, and the 
meatus is sufficiently capacious, to allow a small curved 
knife or scissors to be passed to its pedicle, which is not 



204 CHRONIC DISEASES OF THE EAR. 

very probable ; the practitioner will in that case be ob- 
liged to depend upon the careful use of escharotics. 

The Fungoid Excrescence is by far the most common 
growth from the surface of the meatus, and is very usu- 
ally met with in long continued otorrhea of this canal. 
In some cases the tumour is merely a hypertrophy of 
the mucous membrane, but in most instances it is a 
diseased exuberance, consisting occasionally of morbid 
granulations from an ulcer or sinus, in the latter case 
being projected through the opening, the excrescence be- 
comes much expanded. 

The fungus presents the appearance already described, 
being generally irregularly divided into different portions 
at its summit, and has more or less extensive attachments 
to the parietes of the canal. A secretion, varying in 
quantity and quality, is always afforded from the surface, 
and which covering the excrescence requires removal by 
syringing for the purpose of examination. The growth, 
though it general proceeds according to the Writer's ex- 
perience, from the posterior wall, occasionally occupies 
the entire tube, but it is probable in such a case that the 
attachment is limited to a part of the lining membrane ; 
it may also be formed from the surface of the membra na 
tympani. This fungus is sometimes the cause of the con- 
tinued Otorrhsea, the whole discharge being formed from 
it, though generally the rest of the lining assists in the 



PLATE XIII. 

Fig. 1. — The caseous tumour of Emily Jefford's ear. 

Fig. 2. — Polypus of Mr. Martin's ear. 

Fig. 3. — The Polypus in Mr. W.'s ear, as it appeared by merely 
dilating the Meatus. 

Fig. 4. — The Polypus in Mr. W.'s ear, held on one side to 
expose the fungus surrounding its pedicle. 

Fig. 5. — Fungus in Young's ear, partly attached to the Mem- 
brane of the Tympanum. 

Fig. 6. — Mr. Davis' ear, with the Fungus growing from the 
upper wall of the Meatus, and from the Membrane 
of the Tympanum. 



Fig. / 



Plate 13 




~Fhg.Z 




I?ig.3. 



Fig. 4 




Wig. 5. 





Fig. 6. 




,m 



EXTERNAL CHRONIC OTITIS. 



205 



secretion. From among many instances the following 
may be mentioned as illustrations : — 

Martha Price, aged thirty-three, had a dulness of hear- 
ing for two years : last August she experienced pain in 
the ear and side of the head ; eleven weeks afterwards a 
puriform discharge took place from the ear, upon which 
the pain ceased, On examination it was found that an 
abscess had formed behind the cartilaginous portion of 
the meatus, and had ulcerated into the canal, from which 
a fungus had formed, giving rise to a chronic discharge. 
Her health was improved, and the application of a solu- 
tion of nitrate of silver two or three times a day, was at- 
tended with a removal of the excrescence, and consequent 
cure of the OtorrhaBa and deafness. 

" Mr. Thomas Davies, setat. thirty -five. — At six years 
old had scarlet fever, soon after his recovery from which, 
a discharge appeared from both ears, for which various ap- 
plications were made without any good effect. For some 
years no inconvenience beyond the discharge was expe- 
rienced, when he felt something in his ear, which upon 
examination proved to be a polypus (query fungus ?). 
He was under the treatment of Mr. Curtis for some time, 
and was blistered, &c, without advantage. The disease 
was then neglected for fourteen or fifteen years, the poly- 
pus (?) during that period having increased in size so as 
to occupy the whole cavity of the external ear. Mr. 
Maule then removed a considerable portion of it by twist- 
ing it off with the forceps ; this operation was several times 
repeated, and always with considerable pain, and with 
an improvement of hearing corresponding to the quantity 
removed." Upon recent examination the Writer found 
a large fungus occupying the bottom of the canal, and 
completely obscuring the tympanal membrane, from 
which a copious discharge was proceeding ; upon sound- 
ing the membrane, by passing the probe beyond the tumour, 
that portion presented a healthy feel. The Eustachian 
tube was partially closed, and the membrane of the tym- 
panum on the opposite side was perforated. The patient 
has long declined further treatment than syringing with 
warm water (Plate XIII.)- 

26 



206 CHRONIC DISEASES OF THE EAR. 

Upon examining the ears of Edward Young, who says 
he became deaf, in consequence of the violent noise of a 
cannonade while serving in Egypt, about twenty years 
ago, the Author found a large fungus growing from the 
posterior wall of the meatus, which appeared to be also 
attached to the membrane of the tympanum, and a great 
quantity of matter was secreted from its surface. This 
patient has not yet submitted to treatment, in consequence 
of labouring under another affection (Plate XIII.). 

The removal of a fungus is not usually so successful 
as the extirpation of a polypus, for in consequence of the 
diseased state of the dermal membrane the growth is very 
likely to return ; it may, however, be extirpated, either 
by the knife, by twisting it off with the forceps, or in 
some rare instances by the ligature. A rigid after-treat- 
ment will be required, which must be directed also to 
the entire tube. The fungus is more easily controlled 
than the polypus by escharotics ; the Author remembers 
to have removed such a growth from a young lady's ear 
in about a fortnight, by applying to it a few drops of the 
muriate of barytes upon a probe two or three times a 
week ; among the most valuable of these remedies, the 
argenti nilras in substance or solution, and the alumen 
exsiccatum in powder hold the highest rank. 

The numerous little Vegetations of the lining of the ex- 
ternal meatus, which are the product of chronic inflam- 
mation, are an occasional cause of Otorrhea ; they as- 
sume the character above described, and are usually, 
when firm, attendant upon a general thickening of the 
mucous or dermal membrane. These growths may be, 
in most instances, checked or removed by astringents, 
and particularly by the nitrate of silver. Kramer speaks 
highly of the use of a solution of the acetate of lead in 
these cases, and alludes to an instance in which " a sta- 
lactite-shaped growth hung from the superior surface of 
the meatus, very near to the membrana tympani, of so 
remarkable a bony hardness and density that it was im- 
possible to pierce it with the sharpest knife. Yet an im- 
portant improvement in the hearing distance was effected 
by the application of acetate of lead in solution. " 



EXTERNAL CHRONIC OTITIS. 



207 



' Tumours of various kinds, either congenital or arising 
after birth, are also found in the meatus, they occasion 
deafness by mechanical obstruction, and require removal 
in the manner already indicated. As an example : — 

The Ear of Emily Jefford, aged two years, is deline- 
ated (Plate XIII. ), the tumour was congenital and con- 
sisted of caseous matter contained in a cyst ; as it was im- 
practicable to surround it with a ligature in consequence 
of the large size of the base, the Author removed it with 
the scissors ; the slight hemorrhage was readily arrested 
by the introduction of a piece of sponge. 

Mr. Grantham has lately reported in the Medical Ga- 
zette the case of — 

"Thomas Middleton, aged forty -five years, who ap- 
plied to him in consequence of complete deafness of the 
right ear, which, on examination, he found to be caused 
by an osseous tumour growing from the upper and back 
part of the meatus auditorius, extending across and fill- 
ing up the passage so as to interrupt the ingress of sound. 
He broke off the tumour, which was attached to the mea- 
tus by means of a narrowed peduncle, with a strong pair 
of dissecting forceps. The patient compared the separa- 
tion of the tumour to the firing of a large cannon close 
to the head. The hearing gradually became restored." 

4. The Sinus, to which allusion has several times been 
made, usually occurs in consequence of an abscess ex- 
ternal to the meatus, having ulcerated through the car- 
tilage ; the aperture maintained by the constant discharge 
through it, at last becomes callous. The sinus occa- 
sionally extends outwards from an ulcer of the meatus, 
and may or may not be attended with fungoid granula- 
tions. Sometimes there is likewise an external opening 
behind the outer ear, and occasionally a communication 
with a diseased mastoid process. The external table of 
which portion of bone only may be carious or exfoliating ; 
or the sinus may open into the cells, thus obtaining an 
indirect communication with the tympanum; in these 



208 CHRONIC DISEASES OF THE EAK. 

instances osseous spiculse may be discharged through the 
meatus, by which the inflammatory action is maintained, 
and occasionally increased. 

If the sinus be nearly superficial, and the meatus other- 
wise healthy, by cauterising or destroying by some other 
means the margin of the ulcer, the inflammation which 
succeeds may produce granulations, and a cure may by 
these means be effected. Stimulants are used for this 
purpose, and with occasional success, though it must be 
admitted, they are very often unattended with a bene- 
ficial effect. If a more convenient opening can be made 
externally it should not be neglected, but in general the 
aperture in the canal is less troublesome than it would 
be if placed between the Ear and mastoid portion. When 
the mastoid bone is diseased and exfoliating, and even 
when the ulcer discharges abundantly, it may still be 
necessary to make a sufficiently free opening over its site 
to allow the ready escape of the matter and the seques- 
trum, by which means the ear may be saved from con- 
siderable danger. In many instances the sinus will con- 
tinue during life, and the repeated attempts to close it are 
attended with dangerous excitement. 

5. An inordinate Ceruminous Secretion, is very fre- 
quently a consequence of acute, or rather subacute in- 
flammation of the meatus, which terminates by inducing 
a preternatural increase of the normal action. Dr. 
Kramer has described this affection as following erysipe- 
latous inflammation, but he appears to apply to that term 
a signification different to that which is adopted in this 
country. It is not sufficiently understood, that this very 
common accumulation is generally the effect of increased 
action, a circumstance which becomes apparent to the 
careful observer, although as the inflammatory action is 
considerably diminished by the increased secretion, the 
true nature of the affection often escapes detection. The 
cerumen being thus formed in large quantity, becomes 
inspissated by the evaporation, and perhaps partly by the 
absorption, of its fluid particles, and then produces a 
mechanical obstruction to hearing ; in some instances, 
acting as a foreign irritant, it excites disease, generally 
chronic, but occasionally acute. When arising from in- 



EXTERNAL CHRONIC OTITIS. 



209 



creased action, the superabundant wax is often unusually 
fluid, and readily flows out of the meatus. This inordi- 
nate secretion is occasioned by exposure to cold air, fre- 
quently by dirt collected in the meatus ; hence it is often 
met with in uncleanly persons, and it may arise from any 
slight exciting cause. Wax is frequently combined with 
the mucus of chronic Otorrhsea, and sometimes, in the 
early or the latter stages, when the inflammation is mode- 
rate, with the discharge of acute catarrhal Otitis. Such 
an inspissation of wax is a very common effect of the di- 
minished energy of secretion in old age, at which period 
it seems natural that achange should occur in the action 
of the various organs, and in that of the mucous mem- 
branes among the rest, in consequence of which not only 
is the quantity lessened, but the relative constituents of 
the cerumen are altered ; it is darker, more dense, and 
consequently more readily condensed into a hardened 
mass ; and the hairs in the meatus, being now thicker and 
stronger, by preventing the discharge, will facilitate the 
accumulation. Such a condition of the lining of the mea- 
tus occasionally occurs also in young persons, in whom, 
without any inflammatory action, the secretion becomes 
changed from the perfectly normal state, and quickly in- 
spissates, though at this age the torpid action is more fre- 
quently the result of previous excitement. 

When it arises from inflammation, the symptoms will 
depend upon the extent of increased action ; if it should 
be subacute, there will be some itching uneasiness, some- 
times amounting to pain, accompanied by a discharge of 
the wax mixed with mucus ; if it be chronic, the unplea- 
sant feeling is very slight, sometimes not existing, and 
the attention is directed to the affection only by the dry- 
ness of the tube and dulness of hearing. When the in- 
duration of wax depends upon a deficient action, the hear- 
ing becomes gradually impaired, and it is highly important 
to attend to the fact, that this diminution of hearing is 
often erroneously attributed to decreased nervous power, 
a mistake the more liable to arise, inasmuch as the affec- 
tion is generally accompanied by a singing noise in the 
ears. If the real cause be not ascertained, the cerumen 



210 



CHRONIC DISEASES OF THE EAR. 



becomes at last almost of a stony hardness ; and as it 
gravitates to the bottom of the canal, and lies against the 
membrana tympani, it often becomes moulded to that 
surface, and complete deafness is consequently the result. 
Sometimes the wax, becoming viscid and irritating, gives 
rise to an Otorrhsea, which will continue so long as the 
exciting cause remains. It is therefore very requisite 
that in every affection the canal should be very carefully 
examined ; as the disease will baffle every other treatment 
than the removal of the accumulation by syringing with 
warm water. Dr. Kramer and all other authors mention 
several cases of chronic disease of the meatus, which had 
been treated in vain for months, and often for years, when 
a careful examination detected a hardened lump of wax 
lying against the membrane, the removal of which was 
instantly successful in restoring hearing. The ear-picker, 
often introduced by the patient to remove some titillation, 
only scrapes off a little of the surface, and the patient may 
imagine he has removed the whole. 

A medical friend has furnished the Author with the 
following interesting history of his brother's case ; — 

" Mr. M. was afflicted with deafness on one side for 
upwards of sixteen years; he applied to several medical 
gentlemen in York, Hull, &c. ; blisters were applied ; 
different lotions were dropped into the ear, which was 
also syringed, but he found no relief. About 1825 he 
applied to Sir A. Cooper, who gave it as his opinion 
that a small tumour or abscess was forming ; he returned 
to the country, and enjoyed good health, until being 
thrown out of his gig, when his faculties became impaired 
from the injuries he then received. He was advised to 
return to London, and take the opinion of Dr. Armstrong, 
which he did without benefit. He then went to Amster- 
dam, and took frequent warm baths for the sake of his 
general health. Having remained one day in the bath 
for a considerable time, he heard a sudden report, and 
fancied some one had shot him ; and, on looking about, 
he found what appeared at first to be some hard missile, 
about the size of a pea, floating upon the surface of the 



EXTERNAL CHRONIC OTITIS. 



211 



water ; but on further examination at home, it proved to 
be a lump of extremely hardened wax : he heard distinctly 
from that time until his death." 

This case is interesting, by showing how acute obser- 
vers, by not being accustomed to examine the meatus, 
may overlook a very simple cause of disease, and how 
completely the patient's prospects may be marred by this 
apparently trifling circumstance, as this gentleman had 
been obliged to resign a lucrative business in consequence 
of his deafness. Of course the frequent bathing had 
loosened the wax, and then, upon its escape, the sudden 
restoration of hearing occasioned a noise which was 
alarming. 

The Writer removed from the opposite ear of Edward 
Young, to whose fungus allusion has been made, a lump 
of wax, which had been accumulating for many years, 
and occasioned deafness. 

A medical gentleman had been hard of hearing for 
some years, with ringing noises in the ears, a dryness of 
the meatus, and slight uncomfortable sensations occasion- 
ally in the head ; thus the symptoms simulated those of 
nervous affection. His ears had been frequently syringed 
by his professional friends, without the removal of any 
wax, or benefit to the function. In consequence of an 
unusual narrowness and obliquity of the auditory canal, 
it was impossible to obtain a view of the whole extent 
of the tube ; but by sounding with a probe, the Author 
discovered that both meatus were plugged with hardened 
cerumen, the induration being greater on one side than 
the other. The wax was removed by diligent syringing, 
with a perfect restoration of hearing. 

The treatment of this affection is very simple, it con- 
sists in allaying any inflammation which may exist ; and 
in removing the cerumen, whether it be hardened or 
otherwise ; when soft, there will be no difficulty in wash- 
ing it away, which will be the chief means of abating the 
accompanying irritation. When the wax is extremely in- 



212 CHRONIC DISEASES OF THE EAR. 

spissated, sometimes amounting almost to a rocky consist- 
ence, its removal is often difficult, yet experience seems 
to prove that it may always be accomplished by assidu- 
ous syringing. In order to operate effectually, the syringe 
should be larger and more powerful than that ordinarily 
used ; and as those made of brass are more true than 
others, they are best adapted for the purpose. The ear- 
syringe of the London instrument makers is a very excel- 
lent instrument. The auricle is to be drawn upwards 
and backwards, to lessen the obliquity of the canal ; the 
pipe of the syringe to be introduced as far as can be done 
without pressing upon the surface of the meatus ; and a 
full and long stream of warm water is then to be thrown 
along, first one surface, then another, of the tube, so that 
the fluid may be insinuated all round the cerumen : the 
convenience of the basin used will be much increased if 
that side towards the patient be flat, with a concave mar- 
gin. The Surgeon will first ascertain that the tympanal 
membrane is perfect, otherwise the fluid forcibly thrown 
into the cavity may there excite inflammation. In ordi- 
nary cases there is no fear of the water not returning, and 
very little indeed of injuring the meatus of the membrane. 
While the hard wax remains in the canal, rather a plea- 
sant sensation, with a humming noise, is occasioned by 
the syringing, but when the tube is clear, the blow pro- 
duced upon the membrane is sometimes very painful and 
stunning. The operation should be continued for half 
an hour every day till it is successful, unless this be for- 
bidden by the irritability of the part. The dislodgment 
may generally be assisted by the previous introduction of 
a few drops of warm oil, either of olives or of almonds, 
which will lubricate the surface, and may thus loosen the 
indurated wax. Fluids variously medicated have been 
used for the purpose of syringing ; some of them have 
possessed a certain degree of fame, but as the Author's 
agrees with the much more extensive experience of Dr. 
Kramer, that warm water answers the pu rpose as well as any 
other fluid, and is less likely to stimulate, further notice of 
them is not required : many practitioners, however, prefer 
soap and water, and some milk and water, for this purpose. 
When the cause has been removed, it is often necessary 



EXTERNAL CHRONIC OTITIS. 213 

to restore the lining membrane to a healthy action, by the 
application of some gentle stimulant, either in the form 
of a lotion or an ointment, and perhaps the diluted oint- 
ment of the nitrate of mercury will answer the purpose 
better than most other remedies. 

A caution against empirical syringing may here be per- 
mitted, as it has frequently happened that water forcibly 
thrown against the membrane, when unproteced by wax 
or a foreign body, has produced injurious effects, which 
have been more or less lasting. The practice should also 
be conducted with the greatest care, when the membrane 
is known to be ulcerated, or when such a condition is 
only suspected. The unscientific employment of this fre- 
quently valuable remedy has often excited acute disease 
in a predisposed tympanum, and has even induced fatal 
consequences. 

6. Aphthce or Herpetic Ulcerations occur in the lining 
membrane of the auditory meatus ; they are usually the 
consequence of an extension of disease from the auricle 
and neighbourhood, though frequently confined to the 
tube alone ; and are accompanied by chronic inflamma- 
tion more or less extensive, which is generally limited to 
the circumference of each little ulcer. There is often in- 
terstitial effusion, producing a tumefaction of the mem- 
brane, which if much injected with blood-vessels, presents 
a spongy character ; and so great is this distension of the 
membrane in some instances, as to obliterate the tube. 
There always exists a discharge of a thin, often ichorous, 
matter, sometimes bloody, with uneasiness or pain corre- 
sponding to the inflammation ; the hearing is impaired, 
and suspended in urgent cases, when the tumefaction is 
very great. This affection, like the other varieties, may 
continue for many months or even years, with variable 
severity ; and, as in many instances, it also affects the 
surface of the tympanal membrane, the disease under the 
state of great excitement, is in danger of extending to 
the cavity of the tympanum. 

The Treatment should resemble that for chronic in- 
flammation of the meatus ; thus the general health, the 
faulty state of which is the chief cause of the disease, 
should be improved : the use of alterative astringent in- 

27 



214 CHRONIC DISEASES OF THE EAR. 

jections is requisite; and with this view the surface may 
be painted with the black or yellow wash, or with the 
solution of lunar caustic; counter-irritants are also of 
great benefit. 

7. In consequence of long continued chronic inflam- 
mation, or as a sequela of the acute disease, the cartilage, 
or the bone of the auditory canal, occasionally exfoliates. 
In this case the mischief ordinarily extends to the sur- 
rounding structures, and the portion of dead cartilage or 
bone may escape either into the meatus, or through an 
ulcer external to it. It is, however, generally complicated 
with an affection of the mastoid process, or of the tym- 
panum. This form of disease is to be treated on general 
principles, care being taking to form, when practicable, 
a sufficient external outlet for the escape of the bone or 
cartilage. It is unnecessary here to observe how much 
more predisposed, from its structure, the bone is to ex- 
foliate than the cartilage, which, on the contrary, is more 
prone to ulcerate. 



Section II. 

Although it was the original intention of the Author 
to describe the injuries of the organ of hearing in a dis- 
tinct chapter, yet it appears more suitable not to separate 
the subject of foreign bodies in the auditory meatus, from 
the account of the chronic diseases of that tube, as such 
bodies, when present, frequently induce these affections, 
and they simulate each other in their symptoms. 

Foreign subtances are generally introduced by children 
in their moments of frolic, and, as might be expected, are 
usually roundish and smooth, for angular bodies w r ould 
give pain to the little idlers, and they would immediately 
desist ; when these matters are of a soft nature, as beans, 
peas, &c, they imbibe the moisture secreted by the lining 
of the canal, and becoming swollen, they are with increased 
difficulty removed. If the body be round, and so exactly 
fit the tube as not to move within it, nor to afford pres- 
sure ; and if the patient be in health, and the ear not 
irritable, it may remain there many months, giving rise 



FOREIGN BODIES IN THE MEATUS. 215 

to little or no inconvenience, and even in many cases 
hardly interrupting the progress of sound. In instances 
of a different description, chronic inflammation is excited, 
occasioning an Otorrhea, the cause of which may not be 
suspected ; which circumstance alone, if there were no 
other, imperatively demands that the Surgeon should 
most accurately examine the meatus, and have the mem- 
brane of the tympanum, if possible, clearly exposed to 
his view in every case of disease connected with that 
part of the organ. Acute inflammation is also sometimes 
excited by such a foreign irritant. Frequently the body 
remains innocuously for many months, and then produces 
excitement and all its consequences, which may not occur 
until long after the sufferer has forgotten the circum- 
stance of the introduction of the substance ; therefore the 
vulgar fear " that a stone in the ear will eat its way into 
the brain," is not altogether unfounded. 

The symptoms indicating the presence of such a fo- 
reign body, are those of the excitement it produces, and 
ocular or tactile demonstration of the fact ; but sometimes 
such demonstration is with difficulty obtained ; in con- 
sequence both of the pain occasioned by the necessary 
dilatation of the meatus, and particularly of the body 
being surrounded by fungoid growths, the result of the 
inflammation or ulceration that has been induced ; in 
these untoward cases the examination by the probe will 
often afford much assistance, and indeed the fungi may 
frequently be so far separated as to bring the offending 
body into view. 

The medical periodicals teem with unfortunate cases, 
arising from this cause ; it will, however, suffice to men- 
tion one or two of many that have been seen by and re- 
lated to the Author : — 

" Mr. G. S., a Surgeon, when eight years old, pushed 
a pea into his ear ; for some few days it was not noticed ; 
the medical attendant was then sent for, who removed 
only a portion, and that with great difficulty ; at the end 
of a week the remainder was extracted with comparative 
ease by his mother; for some time no inconvenience was 
experienced, when a fetid discharge appeared, for which 



2X6 CHRONIC DISEASES OF THE EAR. 

astringent iujections were employed without benefit. 
Nothing further than the use of applications for the pur- 
pose of cleanliness, was resorted to for nearly twenty 
years. Almost total deafness existed during the whole 
period. Two years since, when travelling on the outside 
of a coach on a very hot day, violent pain was felt in the 
affected ear ; and for two or three days an itching there 
attracted notice, and a probe being passed down, a black 
body about the size of a pea fell from the meatus ; neither 
deafness nor other inconvenience has been since experi- 
enced. " 

The Writer has very lately examined the ear, and 
found the meatus and tympanal membrane quite healthy, 
and rather of an unusual size. There can be but little 
doubt that this body was a part of the pea, which had 
thus remained so long in the tube, and had escaped the 
investigations of a great number of practitioners, who 
had examined the canal during that long period. 

Harriet Bullock, when between six and seven years of 
age, put a stone into her ear ; it gave rise to no inconve- 
nience until about eight years afterwards, when she suf- 
fered more pain than she could express; her agonies, 
which she referred to the ear, were at times so severe, 
that in order to prevent self-violence, it became neces- 
sary to secure her. Upon passing a pin down the meatus 
one evening, she heard it scratch against something, and 
was then reminded of the stone she had introduced so 
many years previously, and which had been entirely for- 
gotten. The pebble was about the size of a horse-bean, 
and so firmly attached to the parietes of the canal, and 
surrounded by ■ fleshy growths,' that an accomplished sur- 
geon had great difficulty in removing it ; he tried various 
forceps before he could grasp it ; at last he succeeded, and 
in a short time her recovery was complete. 

Mr. Stevenson has reported in the Edinburgh Journal 
the interesting case of Lieutenant Colonel Smith, (i who 
consulted him on the 25th July, for a troublesome dis- 
charge from the right ear, accompanied with almost total 
deafness. In the previous May whilst riding, his horse 



FOREIGN BODIES IN THE MEATUS. 



217 



sprung out of the road, and forced him with great violence 
against some branches of a tree, from one of which he 
received a most severe blow on the right side of his head. 
The concussion rendered him nearly incapable of main- 
taining his seat in the saddle. Immediately on recover- 
ing himself, he felt a very acute pain in the injured ear. 
The Staff Surgeons found the integuments of the auricle 
considerably bruised and lacerated, and the concha and 
meatus filled with coagulated blood. The latter was re- 
moved by syringing with warm water. The local pain 
and irritation instead of subsiding, as was expected, ra- 
pidly increased, and soon induced a high degree of sym- 
pathetic fever, with slight delirium. These symptoms 
were, in a few days, alleviated by the formation and sub- 
sequent escape of a considerable quantity of pus from the 
meatus. After this period, scarcely any uneasiness re- 
mained, except on pressing the tragus, which was invaria- 
bly followed by a very pungent and deep-seated sensa- 
tion. This, together with the deafness and discharge, 
was regarded as the mere consequences of the preceding 
inflammation ; for which the ear was washed with warm 
milk and water, and different injections. When he 
arrived in London an attentive inspection of the organ en- 
abled Mr. Stevenson to discover something projecting from 
an accumulation of matter at the farther extremity of the 
passage, which, by the introduction of a probe, was 
ascertained to be a solid and slightly moveable substance. 
The Colonel instantly suggested its being a portion of 
fractured and detached bone : a suspicion he had con- 
stantly hinted to his different medical attendants. It 
was extracted with some difficulty ; and, when cleared 
from the adhering discharge, it proved to be a rough irre- 
gular flat splinter of oak, five lines in length, and three 
in breadth : one extremity of which, being pointed, had 
penetrated anteriorly, and in an oblique direction, to the 
depth of nearly two lines between the cuticular lining 
and the parietes of the bony canal, close to the membrana 
tympani. Its presence and position satisfactorily account 
for the symptoms. Its removal afforded immediate relief 
from pain, with the most perfect restoration of hearing ; 
the ulcer also rapidly healed, and all discharge ceased." 



213 CHRONIC DISEASES OF THE EAR. 

Mr. Stevenson observes on this case, that it is very re- 
markable that greater and more permanent mischief did 
not result from the irregularity of the wood, its position, 
and length of time it remained. 

He alludes also to a case, related by Hildanus, " of a 
girl twelve years of age, who accidentally let a glass ball 
fall into her left ear. Such was the succeeding inflam- 
mation and so violent the pain, that the whole half of the 
head, and even the extremities of the same side became 
affected. To these were added other alarming symptoms, 
which continued for eight years, and only subsided by 
the removal of the cause." 

Bartholine represents his wife to have been for a long 
time tormented with a pain round her ear, which was at 
last remedied by small stones being spontaneously dis- 
charged from the auditory passage. 

The Author removed with his probe without much 
difficulty a stone from a child's meatus, which had been 
impacted several months without producing much incon- 
venience. 

The Treatment consists in the removal of these extra- 
neous bodies, and it will often be necessary for the Sur- 
geon to risk exciting considerable pain to accomplish this 
all desirable object. It is evident that the longer it is 
delayed the more difficult will be the extraction ; and 
unfortunately it often happens, that the body being 
pushed farther in, by awkward attempts at removal, be- 
comes more firmly impacted, lacerates the lining mem- 
brane, and sometimes is forced against, or even through 
the membrana tympani. Sir A. Cooper has depicted a 
membrane torn in the attempt to remove a foreign body, 
of which a copy is given (Plate XII., fig. 6). If the sub- 
stance be near the outer extremity, and particularly when 
not occupying the entire calibre of the canal, it may be 
easily seized with a pair of forceps and removed; the 
blades of the forceps should be thin, not very narrow, 
and furnished with well formed teeth, and perhaps they 



FOREIGN BODIES IN THE MEATUS. 



219 



will be more convenient if their opposed faces are slightly 
concave. The eye-probe a little curved, may often be 
carried behind the body to be removed, when the forceps 
cannot be effectually used ; two probes may be passed 
along opposite surfaces of the substance, being bent some- 
what into the shape of midwifery forceps and fastened 
together, and thus the material will be firmly grasped 
between them. A small hook, or pair of hooks, may be 
fixed in a soft substance, though it may be impossible to 
surround it; the Author has one blade of his ear-forceps 
furnished with two projecting teeth, between which are 
received a single tooth of the opposite blade, resembling 
Assellini's ; such an instrument is well adapted to re- 
move fungi. A large body impacted in the meatus should 
be cut through if practicable, by which its extraction 
would be much facilitated ; this object may often be ac- 
complished even when the substance is hard, by the in- 
strument used by Mr. Costello for dividing calculi fixed 
in the urethra. The Surgeon's inventive ingenuity will 
often be in requisition, when the forceps are inappli- 
cable in these cases. If much trouble is expected, it will 
be better to lubricate the canal with warm oil previous 
to attempting the extraction. 

In some rare cases where the danger attendant upon 
removing the body in the ordinary manner is great, either 
in consequence of the large size of the substance, — the 
depth to which it has been introduced, — the narrowness 
or obliquity of the auditory canal, or the degree of in- 
flammation already excited, it may be advisable to make 
an incision between the lower and back part of the mea- 
tus and mastoid portion down to the tube, the cartilagi- 
nous portion of which may then be laid open, and the 
body more readily exposed to view and grasped with the 
forceps. 

As illustrative of the great difficulty which occasionally 
occurs in these cases, and of the unfortunate result which 
may arise from the Surgeon's mind being pre-occupied 
by a strong impression, the following abridged report 
from the Lancet, may be transcribed : 

" A boy, seven years of age, on Friday whilst at play, 



220 CHRONIC DISEASES OF THE EAR. 

put the round head of a nail into his left ear. He was 
unable to get it out again, and his father took him to a 
Surgeon for the purpose of having it extracted. This 
gentleman told the father that he could distinctly see the 
head of the nail, and that if the boy would allow him he 
could easily remove it. The boy objected strongly, and 
it was necessary to have him held by four men, but 
their efforts were not sufficient to retain his head at rest, 
and consequently no attempt at extraction was made. 
On Monday he was taken to a public institution, and 
when there he objected so strongly to the examination of 
his ear, that it was necessary to have him held by seve- 
ral assistants. This being done, the Surgeon introduced 
a probe, which, when it had been passed about an inch, 
could be distinctly heard to strike some metallic substance, 
which appeared to be firmly impacted in the tympanum. 
As it could not be removed with the probe, several pairs 
of forceps were successively introduced, and with each of 
them the piece of nail was taken hold of, but could not be 
extracted. The Surgeon used as much force as he 
thought prudent, and from the boy's efforts to get away 
his head, he must have lacerated the membrane lining 
the meatus, which was followed by tolerably copious he- 
morrhage. He was then ordered to be placed in bed, to 
have his ear syringed with warm water, and afterwards 
a bread and water poultice to be applied, and in the eve- 
ning, six leeches to the ear. Thursday. — He has suf- 
fered no pain in his ear or head ; the several functions 
are regularly performed, and he appears perfectly well. 
There is a free discharge of pus from the ear. On the 
morning of the following Thursday the discharge from 
the ear stopped, and he complained of headache. Fri- 
day. — Much better ; the leeches to be repeated. Satur- 
day. — He has very little pain in the head, and appears 
free from the symptoms which attacked him on Thursday. 
The Surgeon requested his colleague to endeavour to ex- 
tract the nail, which he immediately proceeded to do. He 
began by introducing into the meatus, a director, which 
he used with so much force, that he bent it ; dressing 
forceps were then employed, with which he laid hold of 
the nail, and pulled so forcibly, that he bent them also. 



FOREIGN BODIES IN THE MEATUS. 



221 



Another pair was tried, which unhappily met with a simi- 
lar fate. A pair of forceps with hooks at the extremities 
was then used, but they were soon bent straight ; several 
attempts were made with different instruments, but the 
nail could not be moved, though the operator exerted 
great strength on the occasion. An incision of about an 
inch long parallel to the posterior part of the ear was 
made, and the meatus auditorius was divided. The nail 
was again searched for, and forceps of different kinds 
were repeatedly introduced, but they either bent, or slip- 
ped their hold every time. An elevator was had recourse 
to, but it was equally unsuccessful. A pair of tooth for- 
ceps was next employed, and after laying hold of the sup- 
posed nail, and pulling very forcibly, the Surgeon at 
length succeeded in extracting three pieces of metal, 
which appeared to be portions of the head of a nail. En- 
couraged by this success, he introduced the forceps again, 
and extracted the mallet bone ; they were again repeat- 
edly introduced, and though the Surgeon enclosed the 
head of the nail between the extremities of the forceps, 
(as he said) nothing but portions of bone were extracted. 
A pair of wire nippers w r as now called for, in order to 
cut the nail in two ; but some gentleman observed, that 
they would be too large to be introduced into the tympa- 
num. He said, that it was evident that the nail was bent, 
and was ' lying in the posterior part of the tympanum,' 
and talked of trephining the mastoid cells, but soon aban- 
doned the idea. On looking through the incision which 
had been made, bone could be seen at the bottom of a 
deep cavity. The Surgeon said it was the external boun- 
dary of the tympanum, and thought that the nail was 
lying against it; but he again in a few minutes changed 
his opinion, and said he did not know where it was. The 
patient had now been on the table about an hour, and it 
was found that he was nearly exhausted : his pulse could 
scarcely be felt, and his skin was bedewed with cold per- 
spiration. Some wine was offered him, which he re- 
fused ; his pupils were dilated, and it was considered ne- 
cessary to desist from any further attempts ; to have him 
put to bed, and to have a bread and water poultice ap- 
plied to the ear, and to give ten drops of Liq. Ant. Tart. 

28 



222 



CHRONIC DISEASES OE THE EAR. 



every four hours. The operator then stated that, ' he 
had used more force than was warrantable.' He con- 
soled himself, however, that there was now a large open- 
ing through which pus might escape if it should form, 
but yet he feared that part of the petrous portion of the 
temporal bone would exfoliate, and that inflammation 
would come on in the brain, and occasion abscess and 
death. He stated that he had seen three or four similar 
cases which had terminated in this manner ! Sunday. 
— Has not spoken since the operation ; he has been insen- 
sible ever since, — groans a good deal, as if in pain, — 
pupils very much dilated, and the approach of a lighted 
candle occasions very little alteration in their size. There 
is no discharge from the ear, — pulse very rapid, and 
scarcely perceptible, — bowels open once during the 
night. His mouth cannot be opened sufficiently wide to 
allow his tongue to be seen. He has not slept since yes- 
terday. A blister was ordered to be applied to the back 
of the neck, and to take ten grains of Hyd. c. Creta every 
eight hours. Monday. — Is perfectly insensible; has 
not spoken since Saturday. He continued to groan loudly 
till ten o'clock last night, but since then he has been per- 
fectly quiet. Countenance is now cadaverous, and lips 
are exsanguine, — eyelids half closed, — right pupil very 
much dilated, — left contracted, — a lighted candle 
brought close to them occasions no change, — pulse can- 
not be felt in either wrist, — the heart beats very feebly, 
and rapidly, — respiration hurried and frequent, — there 
is also gargouillement, — bowels not open since yester- 
day. Saliva is seen flowing from the corner of the mouth ; 
skin bedewed with cold clammy perspiration. He has 
taken his medicine regularly, — blister has not risen, — 
he appears to be in articulo mortis. He was visited 
about one o'clock, but found that he had been dead about 
an hour. 

" Post-mortem examination four hours after death. 
Head. — About four ounces of serum were found, between 
the dura mater and arachnoid membrane. There was 
softening of the entire extent of the base, and of the an- 
terior part of the hemispheres. The vessels on the sur- 
face were very much distended, but the substance of the 



INSECTS IN THE EAR. gOS 

brain was pale. The ventricles were examined, but 
nothing particular was discovered in them. 

" Ear. — The temporal bone being removed from the 
skull, and the soft parts stripped off, the cavity of the 
tympanum was immediately brought into view, without 
anything else being done. Not a vestige of the bony 
portion of the meatus auditorius externus remained, the 
whole having been removed in the operation, and the 
floor of the tympanum was also wanting. The remaining 
portion of the tympanum was covered with pus, which be- 
ing washed off, the surface of the bone beneath seemed 
highly inflamed. The nail not being in the tympanum, 
sections were made through the cochlea, vestibule, semi- 
circular canals, and mastoid cells ; but there was no 
nail to be found !" 

The injurious consequences which may arise from the 
extraction or the previous presence of these bodies, are 
to be remedied accordingly. 

It is quite distressing to read the details of dreadful 
suffering produced by the presence of insects and worms 
in the meatus, and sometimes also in the tympanum. 
Doubts still exist as to the manner in which these beings 
obtain a residence in the human Ear : certainly, they 
are generally formed by insects being attracted into the 
auditory canal, by the discharge which may be going on, 
and there depositing their ova, which in time are con- 
verted into worms ; the eggs may be dropped upon the 
orifice of the tube, and be afterwards conveyed inwards 
by the cilice, if such exist in the Ear ; it is also possible 
that they may be generated there in the manner in which 
the entozoa are supposed to be formed in the intestine, 
and other parasitic animals in the different structures of 
the body. It has likewise been imagined that worms 
may crawl into the meatus of a person lying upon the 
ground asleep. However they may obtain possession, 
numerous cases are recorded of their existence, and of 
the dreadful sufferings produced by them. The symp- 
toms to which they give rise are those of irritation, gene- 
rally of intense character, and often passing on to sup- 
puration ; and as these animals usually are found in cases 



224 CHRONIC DISEASES OF THE EAR. 

of otorrhsea, the disease is exasperated by their presence, 
and if the tympanum were not previously affected, it 
generally soon becomes implicated. They collect in large 
quantities in the tympanal cavity, and it appears also in 
the mastoid cells; and increasing in their size and number, 
they in proportion augment the sufferings of the patient. 
Itard relates several cases, most of them quoted from other 
writers : — 

"A boy, six years old, was afflicted with slight suppu- 
ration of the meatus of the left Ear, unattended with pain ; 
but little was done for it. In about a month he com- 
plained of acute pain, which was relieved by bland tepid 
injections; this continued to return, and was relieved; 
at length the intervals of ease were shorter : in a few 
hours it became so acute, as to produce convulsions, and 
some drops of blood escaped from the Ear; bleeding and 
anodynes were resorted to without effect. The agony 
and convulsions continued, with hemorrhage from the 
Ear, for two days, notwithstanding the bleedings and nar- 
cotics, general and local. About seven in the evening 
the convulsions became less violent, the pain diminished, 
and the patient complained of something gnawing his 
Ear. His mother, who was alone with him, perceived 
a white body in the auditory canal, and having intro- 
duced a needle, succeeded in extracting a pretty large 
white worm, which she threw hastily on the ground, 
where it writhed and crept about. Terrified at this oc- 
currence, she immediately sent for the medical attendants, 
who instantly recognised the cause of the child's suffer- 
ings, and, as these had not entirely disappeared, suspect- 
ed that some of these animals might still remain. By 
means of small forceps, the Surgeon extracted two worms, 
similar to the first. The hemorrhage then ceased, the 
pain subsided, and the convulsive motions disappeared; 
the child quickly fell asleep, and when he awoke, seemed 
quite well, with the exception of a slight suppuration in 
the auditory canal, which in a few days subsided. The 
worms were inclosed in a phial, in which they were, in 
the course of thirteen days, converted from the chrysalid 
or pupaceous to the flying condition, when they were re- 
cognised to be the same species of flies which frequent 



INFLAMMATION OF THE MEMBUANA TYMPANI. 



225 



places occupied by putrefied animal and vegetable 
matter." 

Acrel mentions the case of a " woman, who had been 
deaf a long time, and was suddenly seized with acute 
pain in the ear, and violent convulsions, without appa- 
rent cause. They several times returned, and became 
more vehement. A piece of lint, moistened with oil and 
laudanum, was introduced into the meatus, and on re- 
moving it the next day, several small round worms were 
observed upon it, and from that period all symptoms dis- 
appeared. Valsalva reports a case, somewhat similar, 
but of longer continuance, in which the membrane of 
the tympanum was destroyed, and worms, like small 
silk-worms, were discharged at long intervals." 

If these creatures can be seen in the meatus, they must 
be immediately removed with the forceps ; if they be too 
small or numerous to be seized by the instrument, a 
pledget of lint covered with oil and honey may be intro- 
duced, to which they will sometimes adhere ; a few drops 
of the infusion of tobacco in the oil of almonds may be 
passed down the canal, or the smoke of tobacco may be 
used, which does not appear to injure the tube, but is fatal 
to its noxious inmates ; if the tympanum be exposed, and 
the worms are contained in it, the smoke of tobacco may 
be thrown through the Eustachian tube, and be thus 
brought into more immediate contact with them. 



Section III. 

CHRONIC INFLAMMATION OF THE MEMBRANA TYMPANI 

Will not require so extensive a discussion as its im- 
portance deserves, in consequence of most of the diseases 
described as appertaining to the auditory canal, affecting 
likewise this important membrane; and because the 
observations then made are likewise applicable to the 
affections of this structure. 

The membrane, however, is sometimes chronically 



226 CHRONIC DISEASES OF THE EAU. 

inflamed, independently of disease of other structures ; 
and this may be produced by any of the causes of in- 
creased action. Although this affection is often the con- 
sequence of acute inflammation, yet it more frequently 
commences in the chronic state. 

The Surgeon can only ascertain the precise condition 
of the organ by accurate inspection; the symptoms can- 
not be distinguished from those of disease of the mea- 
tus, or of the tympanal cavity. Dulness of hearing is 
induced, varying in degree according as the extent of 
altered structure interferes more or less with the vibrati- 
bility of the membrane ; and very often from this cause 
alone the cophosis is nearly complete. There is also 
uneasiness referred to the bottom of the meatus, some- 
times a pricking sensation, and even pain, extending into 
the deeper structures of the organ, and to the head. In 
most cases a discharge occurs from the canal, varying in 
quantity and quality, and in both conditions frequently 
changing, which is secreted by the surface of the dis- 
eased membrane ; but this is by no means always the 
case. The Author has very recently examined the Ear 
of a woman who has long been very deaf; formerly a 
fluid escaped from the canal, but it is now and has been 
for some years unusually dry and capacious ; the mem- 
brana ty mpani presents a white opaque appearance, seems 
to be less than usually concave, and the attachment of 
the manubrium of the malleus is not distinguishable. 

The organic alterations in this structure produced by 
chronic disease are very numerous. The usual appear- 
ances of this degree of inflammation may exist, as red- 
ness, varying from a slight tinge to a dark brown, occu- 
pying the whole surface, or confined to different spots. 
The membrane may be simply thickened and opaque, 
somewhat resembling the appearance of the nebulous 
cornea. Little incrustations may cover its surface, and 
which will occasionally fall off; these are sometimes ad- 
hesive deposits, and in other instances inspissations from 
the muco-purulent secretion. Little hardened vegetations, 
more or less vascular, may partially occupy the surface of 
the membrane ; and from it also polypi or fungi occa- 
sionally proceed ; these growths, as in the meatus, vary 
in different cases from extreme softness, resembling a 



INFLAMMATION OF THE MEMBRANA TYMPANI. 227 

congeries of bloodvessels to a scirrhous hardness. They 
give rise to a similar train of symptoms, as when seated 
in the meatus, excepting that the deafness is usually 
more complete, and the danger of extension to the tym- 
panum is greater. The most constant effect of chronic 
inflammation of the tympanic membrane is ulceration, 
which, as in other structures, may vary in extent from a 
minute perforation, to a complete destruction of the whole 
membrane : the ulcer generally commences immediately 
in front of the inferior point of the malleus, or below it, 
rarely behind it ; sometimes a central flap of the mem- 
brane alone is remaining, to which the malleus may con- 
tinue to be attached ; more frequently the whole is re moved , 
except a narrow border round the entire circumference ; 
and in numerous instances no trace whatever of this 
structure is left. When the membrane is so extensively 
lost, the ossicula auditus are also implicated in the de- 
struction ; the malleus must be removed ; and generally 
also the incus, with the orbicular, leaving the stapes 
attached to the fenestra ovalis and its membrane. It 
sometimes, but not commonly, happens, that the incus 
still continues united by its short process to the parietes 
of the tympanum, notwithstanding the loss of the malleus, 
of which a case has been already described ; and when 
this occurs the bone can be readily seen (Plate XII., 
fig. 12). 

An inexperienced observer may hardly be able to detect 
the ordinary appearance presented by the entire loss of 
the membrane ; as all will appear dark to his view ; and 
it is sometimes difficult for the more experienced exami- 
ner into the state of the ear to ascertain the presence or 
absence of the stapes, in consequence of the, perhaps, 
unusual length and narrowness of the auditory tube, but 
more especially because of the obliquity of the cavity, 
and of the little bone presenting only its small head, being 
deeply seated, and thrown into shade by the projecting 
promontory. A little glistening spot may, however, 
generally be recognized above the anterior part of the 
promontory, which is the head of the ossiculum, whereas, 
were it absent, a dark spot would occupy that point. 

In order that the Surgeon may be enabled to look com- 



228 



CHRONIC DISEASES OF THE EAR. 



pletely through the meatus to the membrane, and perhaps 
into the cavity of the tympanum, it is necessary to remove 
the natural obliquity of the auditory canal, as well as to 
dilate the tube, and to throw a strong light to- its very 
bottom. It is evident that these indications are much 
more easily accomplished in some persons than in others. 
The Author frequently examines an ear, in which, by 
simply drawing the auricle upwards and backwards, the 
membrana tympani is exposed in consequence of the 
great capacity, slight obliquity, and short course of the 
canal ; whereas, in others, it is with considerable diffi- 
culty a good view can be obtained, the conditions being 
the reverse. In many cases the tube may be sufficiently 
dilated for the purpose of investigation, by drawing with 
one hand the auricle upwards and backwards, and with 
a probe in the other pressing the anterior wall of the 
meatus forwards. This proceeding ought not to super- 
sede the use of the speculum, which in all instances more 
completely dilates the tube and removes the obliquity ; 
in addition to which the unpleasantness to the patient is 
not so great from the more general pressure of this instru- 
ment as from the use of the probe ; the polished surface 
of the speculum will also increase by reflection the quan- 
tity of light; and the Surgeon's hands, being out of the 
way when holding only the handles, will not interfere 
with his view ; it is therefore better in all cases to employ 
this instrument, and this will be particularly evident upon 
witnessing to how great an extent the canal may be gra- 
dually dilated by this method, without producing incon- 
venience. The rays of light are to be direct, and made 
to pass quite to the bottom of the tube, the quantity may 
be advantageously increased by a reflecting medium con- 
veniently placed for that purpose ; hence it will follow 
that the sun's direct rays should be taken advantage of, 
whenever practicable; and if the light of day be but ob- 
scure, artificial illumination must be had recourse to, and 
the more the light is concentrated upon the meatus the 
better ; a wax taper generally answers the purpose very 
well ; an Argand lamp still better, but unfortunately it is 
less useful than otherwise it would be, from its want of 
portability. Kramer has depicted, in his work, an Argand 



INFLAMMATION OF THE MEMBRANA TYMPANI. 229 

lamp placed in a box, furnished with reflectors, and a tube 
converging the light to one small space, and in the brilliant 
collection of rays thus formed the ear is to be placed ; 
such a convenient contrivance is very simple, and often 
used for other purposes. 

Different specula have been used at different times, 
that generally in vogue in this country is very similar to 
the one used by Itard. Deteau, and other Surgeons on 
the Continent ; a little variation has been lately made, in 
giving it a greater curve backwards from the blades, that 
it may be less in the way of the tragus, which may be an 
improvement, but it is a trifling one. Kramer's speculum 
has the blades so constructed, that when closed they form 
a- circular, and not an oval tube, with their points much 
contracted. 

The Author finds, upon experience, that Kramer's 
modification is much less convenient than that in general 
use, as the sharp edges of the narrow extremity produce 
pain, by injuring the lining of the osseous portion of the 
canal; and when the instrument is not introduced far 
enough to produce that effect, it is altogether useless 
(Plate XVL, figs. 1, 2). 

It is known to every practitioner of aural surgery, that 
the patient rarely complains of the stretching of the outer 
division of the canal, but directly attempts are made to 
enlarge the osseous part, pain is occasioned ; yet it is also 
requisite to make a certain degree of distension upon the 
lining of that part of the tube. 

When an aperture, larger or smaller, exists in the mem- 
brana tympani, air may be forced through it from within ; 
this is effected by the patient closing the mouth and nos- 
trils, when, upon making a forcible expiration, as in blow- 
ing the nose, the air must pass through the Eustachian 
tube into the cavity of the tympanum, and find its way 
out through the imperfect membrane. The rushing of 
the air is sometimes so distinct as to disturb the hair 
hanging over the meatus, to flicker the flame of a candle, 
and to be distinctly felt or heard as a whistling sound by 
the attendant ; when mucus or other matter is in either 
of the canals of the tympanum, a gurgling noise will be 
produced, and air-bubbles, if in the meatus, will be seen 
mixed with the fluid. By this little experiment, a perfo- 

29 



230 CHRONIC DISEASES OF THE EAR. 

ration of the membrane may often be detected, when a 
fungus or other tumour conceals it. When warm water 
is injected through the catheter introduced into the Eus- 
tachian tube, it will generally escape by the aperture of 
the membrane into the meatus. The Author has in this 
manner detected the existence of an imperfect membrane 
in a child, in whom, being deaf and dumb in consequence 
of fever during its infancy, it was impossible to make any 
other investigation. The presence of these signs clearly 
indicates the imperfect state of this structure, but their 
absence is no proof of the contrary ; some persons, as 
children, cannot be taught to make the necessary effort 
of expiration, and frequently the Eustachian tube being 
closed partially or completely, or the cavity of the tym- 
panum being occupied by pus, mucus, or blood, the trans- 
mission of air will be prevented. 

Sounding the membrane by carefully striking it with 
the probe, will assist in indicating its condition ; if perfect, 
it will present an elastic feel, produce pain, and excite a 
noise, and unpleasant sensation distinct from pain; when 
it is diseased, or ulcerated, the pain will be generally less, 
the elasticity imperceptible, and the noise not excited ; 
when the probe passes through an aperture of the mem- 
brane, it is distinctly recognized to strike against the inner 
osseous wall of the cavity. (a) 

In the Treatment of Chronic Inflammation of the Mem- 
brana Tympani, and its effects, the Surgeon must never 
forget that there is much greater probability of stimula- 

(a) " The diagnosis of chronic inflammation of the membrana 
tympani may always be established, by syringing out the mea- 
tus perfectly clean ; investigating it by the aid of the speculum 
in bright sunshine ; and testing with the probe the sensibility or 
insensibility of the thickened membrana tympani, and of the poly- 
pous excrescences which cover it. Should the perforation of the 
membrane not be evident, and therefore doubtful, the patient 
should first endeavour to inflate the cavity of the tympanum, by 
making an effort to blow the nose, with the mouth and nostrils 
closed. If the air does not then pass through and out of the mea- 
tus with a whizzing noise, a stream of air should be directed into 
the cavity of the tympanum, from the air-press, by means of a 
catheter, in the manner hereafter to be described, which will cer- 
tainly pass up to the membrana tympani, and through the 
meatus." — Kramer. 



INFLAMMATION OF THE MEMBRANA TYMPANI. £31 

ting applications exciting inflammation of the tympanum 
than when they are applied solely to the meatus. With 
this caution the treatment will be the same as for similar 
diseases affecting the auditory tube. The judicious prac- 
titioner will therefore very gradually increase the strength 
of the astringents and escharotics which he may deem it 
advisable to employ ; and will rather apply them upon 
a -camel's hair pencil-brush, than by means of injection. 
Dr. Kramer strongly recommends, as the most effica- 
cious application to the chronically thickened and in- 
flamed membrane, a solution of the acetate of lead, vary- 
ing in its strength from one grain to ten in an ounce of 
water ; when used in the last proportion he says, the 
membrane is covered by the fine powder of the salt, and 
its action kept up so much the longer. 

The removal of a polypus or fungus from the surface 
of the membrane must be accomplished, either through 
the agency of astringents, or mild escharotics, or be at 
once cut off with a small curved knife, as twisting or la- 
cerating such a growth would almost certainly be attend- 
ed with a forcible rupture of the membrane, the evil 
consequences of which could not be calculated. 

Dr. Bennett, in his able translation of Kramer's work 
on the Diseases of the Ear, has alluded to the possibility 
of an ulcer of the membrane healing under the influence 
of mercury, and has cited a'case of Mr. Smith's, in which 
such a result did partially occur, the very imperfect cica- 
trix was, however, rapidly reabsorbed ; therefore in the 
present state of our information such an ulcer must be 
considered incurable. 

Chronic inflammation is not the only cause of perfora- 
tion of the membrana tympani. We have seen that* it 
very constantly arises from an abscess of the tympanum, 
from which disease it probably most frequently occurs. 
It may also be ruptured by direct violence ; and among 
other authors, Sir A. Cooper has related a case of lacera- 
tion in the attempt to remove a pin, of which injured mem- 
brane a representation is given, and a copy accompanies 
this treatise (Plate XII., fig. 6). A blow upon the side 
of the head may also cause a rupture ; by compressing, 
according to Sir A. Cooper's idea, the air of the meatus 
forcibly against the membrane; this effect may probably 
also occur by the extension of concussion through the 



232 CHRONIC DISEASES OF THE EAR. 

cranial bones. Injuries, by producing extravasation of 
blood into the tympanal cavity, may occasion appearances 
of the membrane in some degree resembling those of its 
chronic inflammation, and it is possible that when the 
effusion is sudden and extensive, the membrane may be 
torn by the pressure. 

An aperture is also made in the membrane surgically, 
for the admission of air into the tympanum, when stric- 
ture or other affection of the Eustachian tube prevents its 
usual mode of entrance. To which operation allusion 
will presently be made. (a) 

(a) Simple opacities of the membrana tympani are declared 
by Kramer to be quite beyond the reach of art. If this membrane 
be considerably thickened, quite insensible on being touched with 
a probe, and of a cartilaginous hardness ; and if, in consequence 
of this, the hearing has seriously suffered, there remains, accord- 
ing to this writer, no other resource but perforation of the mem- 
brane. But before this operation is attempted, the diagnosis 
should, as he very properly enjoins, be made out in the clearest 
manner. 



PLATE XIV. 

Fig. 1. — Master B.'s right ear ; — a small portion of the Mem- 
brane of the Tympanum remaining, well showing 
the Promontory, with the oval and round apertures 
in outline ; — ossicula lost, hearing good. 

Fig. 2. — Master B.'s left ear ; — rather more than the anterior 
half of the Membrane of the Tympanum is removed 
by ulceration, the Malleus being plainly seen attached 
to the edge of the remaining portion ; the posterior 
wall of the cavity seen through the ulcer. 

Fig. 3. — The right ear of Mary Ann Lee, showing the opacity 
of the Membrane of the Tympanum, and a small 
vegetation at its lower margin. 

Fig. 4. — The left ear of John Austin ; — the Meatus occupied by 
an immense fungus, which is represented projecting 
behind the Pinna, through a large aperture in the Mea- 
tus, produced by exfoliation of its osseous portion. 

Fig. 5. — The right ear of Master C. ; — the Membrane of the 
Tympanum entirely lost; the Malleus attached by 
its head and long process to the osseous wall, the 
handle being exostosed ; the Incus seen in outline ; 
the mucous lining thickened. 

Fig. 6. — The left ear of Master C. ; — a small upper part of the 
Membrane remains, giving attachment to the head of 
the Malleus, which is seen to hang below its margin. 



TlaZe 14*. 



-F19L 





':^^-'' 



Fz#3 




'Fjyb. 




Vig.5. 



Fig. 6. 





INTERNAL CHRONIC OTITIS. 233 

Section IV. 

CHRONIC INFLAMMATION OF THE TYMPANUM. 
[Otitis Interna Chronica.) 

A treatise might be composed upon this affection of 
the ear alone, as it is of very frequent occurrence, is 
generally combined with External Otitis, is a common 
cause of more or less deafness, and in its effects is some- 
times fatal by exciting disease in the brain. In the former 
part of this Essay, we have, however, treated so fully of 
Acute Otitis, and have incidentally touched upon several 
points connected with the chronic form, that a more brief 
description than the importance of the subject would 
otherwise require, may suffice on this occasion. 

The seat of the inflammation is the mucous membrane 
of the cavity, but it frequently extends to the cellular 
tissue, and onwards to the periosteum and the bone, affect- 
ing likewise one or all of these structures in the mastoid 
process, as well as in the Eustachian tube. 

In addition to the causes to which allusion has been 
already made in treating of the similar affection of the 
meatus and tympanic membrane, the disease under con- 
sideration is very often excited by the extension of morbid 
action originating in the outer portion of the ear ; though 
more frequently perhaps, it commences in the cavity of 
the tympanum or Eustachian tube, and spreads outwards 
through the membrane to the meatus, rather as a conse- 
quence of Acute Otitis than as a chronic affection from 
the commencement. 

The symptoms of Chronic Internal Otitis, when it is 
an extension from an external disease, do not materially 
differ from those of the latter affection ; but as the in- 
flammation and its consequences extend to the cavity 
they increase in severity ; the slight pain becomes more 
urgent, dragging, pricking, and occasionally shooting 
into the head, — the discharge is more copious, and more 
frequently bloody, — and when the Eustachian tube re- 



234 CHRONIC DISEASES OF THE EAR. 

mains pervious, it often escapes into the pharynx and 
mouth, — the deafness is also much augmented, and if 
the matter discharged be from the beginning carefully 
examined, the malleus or incus, or both, will generally , at 
some time or other, be observed to escape. When the 
disease begins in the cavity the dull heavy uneasiness 
is more severe, accompanied with lancinating pains 
through the head, — the deafness is more considerable, 
and often complete on that side, — and there is frequently 
drowsiness and torpor, with slight delirium, and some- 
times a chilliness, with a little febrile reaction. This 
condition may continue for weeks or months, the patient 
being sometimes better, then again worse. In the ordi- 
nary course of the disease, the membrana tympani ulcer- 
ates, and a discharge suddenly takes place, affording 
considerable relief to the patient, — the matter continues 
to escape, varying as noticed above, and with it, sooner 
or later, the ossicula,and thus an Otorrhsea is established, 
which may exist for a very indefinite period. Usually 
after some months, the discharge ceases ever to be san- 
guineous, it becomes mucous, then almost serous, and 
gradually subsides; during which subsidence the ceru- 
minous follicles by degrees assume their healthy secre- 
tion. Hearing is partially restored, to an extent chiefly 
regulated by the degree of disorganization which has oc- 
curred in the cavity and its contents. 

This is the bright view of a dangerous malady, and 
the one which the Author is happy in thinking most fre- 
quently presents itself. The tympanum on examination, 
affords a variety of appearances; generally the membrane 
lining it is darker and firmer than usual, which is particu- 
larly the case whilst it is secreting pus ; as the disease 
subsides the mucous membrane assumes a more healthy 
appearance. If the membrana tympani be extensively 
removed, the remaining little bone or bones may be dis- 
tinguished ; and water injected gently into the ear will 
pass through the Eustachian tube, producing but little 
inconvenience ; but this effect is more readily produced 
in the opposite direction, by injecting water through the 
Eustachian tube and tympanum into the meatus. At 
other times diseased growths will be detected proceeding 



INTERNAL CHRONIC OTITIS. 235 

from the mucous surface, which are generally mild fungi, 
and as long as they continue, will maintain the diseased 
secretion. It is a common circumstance for the mucous 
membrane to become thickened and spongy, obscuring 
the usual appearances of the exposed cavity, and which 
projecting a little outwards, may be mistaken for a fungus 
of the meatus, or tympanal membrane. When the mu- 
cous lining is thickened and granulated, and affords a 
secretion only sufficient for lubrication, the tympanum 
being filled up, will be defended from the injurious effects 
of variation in the atmosphere and other irritants. 

Unhappily a dark prospect often presents itself during 
the progress of this affection ; the inflammation involves 
the cellular tissue, obliterates by adhesive deposit the 
Eustachian tube, reaches the periosteum, and eventually 
the bony parietes, extending also backwards to the mas- 
toid cells ; which latter process sometimes exfoliates, 
forming an external wound through which portions of 
bone escape, with large quantities of extremely fetid 
matter, and in this manner the tympanum may be re- 
lieved, the natural communication between it and the 
mastoid cells having been considerably enlarged, and the 
cells being often converted into a single cavity by the 
ulceration of their parietes. After distressing the patient 
for many months, even this condition of parts may be to 
a great degree recovered from, and hearing to a certain 
extent enjoyed. Such recovery, however, can only be 
hoped for when the patient's general powers are great, 
and when no exciting cause has been applied during the 
progress of the disease. 

On the other hand, if the disease has existed for some 
time, before the membrana tympani has ulcerated, the 
symptoms of chronic cerebral affection are more urgent, 
— the patient becomes lethargic, and is often with diffi- 
culty roused ; his deafness is much increased with the 
dull weight in his ear, which now extends to the brain, 
producing at times slight delirium, and sometimes ac- 
companied by convulsive motions. Vomiting frequently 
happens after eating, and food is taken sometimes vora- 
ciously, at other times with loathing ; the bowels are 
generally costive, with an occasional diarrhoea, — the 



236 



CHRONIC DISEASES OF THE EAR. 



secretions are diminished, and the patient becomes gradu- 
ally comatose and expires. During this course of the 
disease, the membrana tympani generally gives way, and 
the escape of matter affords some relief to the urgency of 
the symptoms, which is, however, only temporary, as 
they return and the affection progresses to a fatal issue. 
In such a case, and many are recorded, the chronic in- 
flammation, which in the majority of cases has been 
maintained, if not increased to the acute degree, by the 
matter contained in the cavities of the organ becoming 
decomposed, has given rise to ulceration of the petrous 
portion of the temporal bone, and generally either at the 
upper surface or roof, or at the posterior wall of the tym- 
panal cavity, thus reaching the dura mater, which then 
becomes inflamed, and pus is effused between it and the 
bone, or it may be between the cerebral membranes. 
Sometimes the brain itself becomes extensively diseased, 
and suppuration takes place in its structure with thick- 
ening of the membranes. The extent of the caries of the 
bones of the head varies considerably, at one time con- 
fined to a part of the petrous portion, at another occupy- 
ing the whole, and extending to its squamous plate, and 
even to the sphenoid and occipital bones. 

This unfortunate spreading of the disease to the brain, 
still more frequently arises during an otorrhsea from the 
tympanal cavity, which may have existed for a very long 
period without producing more than ordinary inconveni- 
ence ; when, upon the application of an exciting cause, 
either general or local, an increased action takes place, 
and the disease extends more or less rapidly to the mem- 
branes of the brain, or to the brain itself, thus presenting 
all the characters of acute internal otitis. 

The two following abridged reports of Dr. Aber- 
crombie's cases are too interesting to be overlooked, and 
though probably they are known to most members of our 
profession, bat little apology is required for their inser- 
tion, as they are admirable illustrations of the subject under 
discussion. 

" A gentleman, aged twenty, on January 20th, 1820, 
complained of violent toothache, on the right side of the 



INTERNAL CHRONIC OTITIS. 237 

jaw, the pain extended to his ear and afterwards to his 
temple, which partly confined him to his bed. Leeches 
were applied, and aperients were administered, which 
latter he vomited. The pain now affected the head, 
causing him to become delirious, his pulse being seventy, 
and of moderate strength, — the headache still continued, 
especially about the forehead, — his face was pale, — - he 
was still delirious, and his pulse sixty. He was now 
treated antiphlogistically, which he bore well. He seemed 
much benefitted by the treatment, and on examination of 
the ear a fetid discharge of matter was observed, his pulse 
varying from ninety -six to one hundred and twenty. On 
seeing the patient on the 29thj the right eye was observed 
to be suffused* the ball of it turgid and enlarged, and the 
cornea covered with a yellowish slough, — the mouth was 
perceived to be drawn to the left side, — from this time 
he began to sink, and on the morning of the 30th he 
died. 

" Inspection. — There was some effusion under the 
arachnoid on both hemispheres, — much effusion in the 
ventricles* and extensive ramollissement of the septum 
lucidum, the fornix, and the cerebral matter bordering 
upon both lateral ventricles. There was extensive caries 
of the right temporal bone, — behind the ear on the thin 
part of the bone it was very dark coloured, very soft, and 
when cut into, discharged matter from its cancel li, and 
from the cavity of the ear; the dura mater correspond- 
ing to the temporal bone was much thickened. The 
part of it which lay anterior to the petrous portion was 
in a state of recent inflammation, — the part behind the 
petrous portion was much thickened and spongy, — and 
between it and the bone there was a deposition of thick 
purulent matter. From this place the disease had spread 
along the tentorium, over nearly the whole surface of the 
cerebellum, on almost every part of which there was a 
deposition of coagulable lymph, with thick flocculi of 
purulent matter ; this was most abundant on the tento- 
rium, and on the right and posterior parts of the cerebel- 
lum, and it was traced into the fourth ventricle. Under 
the cerebellum there was a considerable quantity of pus, 

30 



238 CHRONIC DISEASES OF THE EAR. 

and in its substance there was a small abscess in the pos- 
terior part betwixt the two lobes." 

Although Dr. Abercrombie does not allude to a dis- 
ease of the ear in this case, previous to the illness of which 
he has given the history, there can be but little doubt 
that such had existed ; this instance furnishes an exam- 
ple of a frequent occurrence, namely, neuralgia of a tooth, 
or several teeth on that side, consequent upon disease of 
the tympanum. 

" A girl, aged nine, had been liable to attacks of suppu- 
ration of the ear, which were usually preceded by severe 
pain, and some fever. On suffering from one of these 
attacks she was not relieved by a discharge of matter as 
formerly, but continued to be affected by pain over the 
forehead, impatience of light and some vomiting ; her 
look was oppressed, the pulse eighty -four. Antiphlogis- 
tic means with mercury were applied, without producing 
relief. She died suddenly about three weeks after the 
attack, having evidenced ail the symptoms of inflamma- 
tion of the brain with convulsions, but continuing sensi- 
ble and without squinting, blindness, or coma. The left 
ear had continued to discharge matter, and an opening 
had formed behind the external auricle, from which also 
there was a purulent discharge. 

" Inspection. — A considerable quantity of colourless 
fluid was found in the ventricles of the brain. The brain 
in other respects was healthy. In the left lobe of the 
cerebellum there was an abscess of considerable extent, 
containing purulent matter of intolerable fetor. The 
dura mater, where it covered this part of the cerebellum, 
was thickened and spongy, and the bone corresponding, 
to this portion was soft and slightly carious on its inner 
surface ; but there was no communication with the cavity 
of the ear. The opening behind the ear merely passed 
behind the external ear, and communicated with the ex- 
ternal meatus." 

Dr. Abercrombie describes a third case, in w r hich in- 
spection after death showed that inflammation had ex- 



INTERNAL CHRONIC OTITIS. 239 

tended from the tympanum to the dura mater, without 
producing caries of the bone. He also alludes to several 
other cases, the perusal of which will repay the reader. 

The Author was requested to see Mr. Gallichan, a 
Medical student, who had been subject to a pain in his 
head, for a considerable time. About a year previously 
he had an attack of toothache, and general pain in the 
face, followed by a discharge from his left Ear, which 
afforded him relief; it continued a few days, and then 
subsided. In about a year afterwards, in consequence of 
taking cold, he was attacked with pain in his head, which 
in a few days was again somewhat relieved by a discharge 
from the affected ear ; the matter was offensive, and he 
was in the habit of removing it with twisted paper. He 
continued occasionally better and worse, but still able to 
attend to his avocations, though his friends noticed that 
he was declining in strength. In about five months after, 
the affection being renewed by taking cold, he was vio- 
lently attacked with pain in the head, which occupied 
the whole of the affected side, and suddenly returning at 
intervals with such severity as to make him jump from 
his bed almost in a state of frenzy, rolling on the floor 
and threatening to throw himself out of window ; though 
confined to his room, he objected to lie in bed, asserting that 
the pain was there increased. For a fortnight previously 
to his death, he was constantly tossing about in a state of 
low delirium ; during these sufferings the ear only occa- 
sionally discharged, and the symptoms of pressure on the 
brain became daily more evident. Antiphlogistic reme- 
dies were utterly useless, and he died comatose. Unfor- 
tunately an inspection of the body was not allowed, but 
the symptoms were so unequivocal as to leave no doubt 
of the extension of disease from the tympanum to the 
membranes of the brain, and consequent suppuration. 

" A young man, aged 17, complained of pain and im- 
mobility of the neck, frequent headache, and a fetid dis- 
charge from the left Ear, which had continued several 
weeks. This discharge had been preceded by acute pain, 
it came on suddenly, and had been very copious from its 



240 CHRONIC DISEASES OF THE EAR. 

first appearance, with an offensive smell. He had been 
deaf in that Ear for some months, but did not seek medi- 
cal assistance until matter flowed from it. The neck 
was then blistered, the Ear syringed, and medicines ad- 
ministered, by which the pain of the Ear was relieved ; 
but the neck became more stiff and painful, so that at 
length he was unable to turn his head in the least. I 
found the muscles on the left side rigid, and every part 
of the neck exquisitely sensitive, but especially near the 
Atlas, and the least jarring motion caused agony. Not- 
withstanding he represented his sufferings to be continual, 
and his nights very frequently dreadful, his appetite was 
good, and his strength sufficient to enable him to pursue 
his employment as a compositor in a printing-office. His 
countenance, however, was extremely pallid and anxious : 
pulse 90, and feeble. From these symptoms I inferred 
that he laboured under otitis, which had probably been 
communicated to the bony structure of the internal Ear, 
and other parts in the base of the skull ; the prognosis 
was therefore unfavourable. Leeches, fomentations, mer- 
curials, and gentle aperients produced intervals of relief. 
The malady, however, evidently continued to advance, 
and at length he could no longer support his head, with- 
out the aid of his hands, nor separate his teeth more than 
half an inch. He lived in continual terror of moving, 
and felt, he said, as if his neck were broken. Consider- 
able distortion of the cervical vertebras was now appa- 
rent ; the spinous process of the dentata projected much 
towards the right side, more than an inch from the mesial 
line, and a slight crepitus could be felt upon passing the 
finger from the first to the second vertebra. On either 
side of the Atlas there was an unusual fulness, but the 
central part appeared depressed, and it yielded to gentle 
pressure, which often seemed to produce a flow of pus 
from the diseased Ear. A burning pain came on in vio- 
lent paroxysms, extending, as he described it, all over the 
inside of his head ; it was excited by the least motion, 
and while it lasted, he raved like one labouring under 
phrenitis; its duration varied from half an hour to two 
or three hours. He became hectic and extremely emaci- 
ated ; obtained no sleep without narcotics, which often 



INTERNAL CHRONIC OTITIS. 



241 



procured a nightf s complete rest. A succession of blis- 
ters were applied, but without benefit. In this miserable 
manner he proceeded, with little variation, for six weeks, 
when, while his nurse was attempting to assist him in 
raising his head to move his pillow, he suddenly became 
paralyzed in every limb. His intellect remained per- 
fectly clear, and his pulse continued about 90; his respi- 
ration was not remarkably affected, but he passed a motion 
without his knowledge. He died calmly, about six hours 
after the occurrence of this perfect paralysis. 

Inspection of the body. — On handling the neck, pus 
flowed abundantly from the Ear. Upon removing the 
calvarium, we found the dura mater rather adherent, and 
more fluid than usual in the arachnoid cavity. The brain 
appeared healthy, except that it was somewhat injected. 
No other signs of disease existed within the skull, but 
pus poured from the spinal canal through the foramen 
magnum. When the muscles of the neck were dissected, 
those of the left side were found degenerated and per- 
vaded by veins of curdled pus. The Atlas was tilted on 
one side, and very moveable. On detaching it from the 
occiput, we discovered that portion of the mastoid pro- 
cess, including the digastric fossa, and that part of the 
occipital bone connected with the left condyle partially 
destroyed by caries. The left occipito-atlantoid liga- 
ments were reduced to a pulp, and the glenoid surface 
was denuded of its cartilage and roughened. The pro- 
cessus dentatus was carious, and its ligaments were ob- 
literated. The theca connected with the first and second 
vertebrae was inflamed, and surrounded by pus, and the 
medulla itself broken down and mixed with sanious 
matter. The ulcerative action had commenced in the 
articulating surfaces of the Atlas and Dentata ; and an 
opening existed between the oblique processes of the 
second and third vertebrse on the right side, which com- 
municated with an abscess amongthe muscles, and opened 
by a small aperture into the upper and back part of the 
pharynx. 

Among the patient's complaints I should mention, that 



242 



CHRONIC DISEASES OF THE EAR. 



not the least troublesome was frequent priapism, with 
involuntary emissions, without sexual desire." 

This case has been given at length, and in the words 
of the intelligent Surgeon who attended it, as the Author 
believes that it is one of the most interesting on record ; 
showing the extensive devastation which the burrowing 
of a tympanic abscess may produce ; the disease appears 
to have extended from the tympanum to the mastoid pro- 
cess, which , becoming ulcerated, the abscess passed through 
the muscles to the spine, &c, producing the disorganizing 
effects above described, and not, as in the more ordinary 
mode, extension to the brain. The unhappy sufferer's 
life was a little shortened by the accidental partial dislo- 
cation of the Atlas. 

" Mrs. Hawes, a poor woman, was the subject of tic- 
doloureux, which was attended with deafness on that same 
side, and occasional attacks of pain in the head accom- 
panied by delirium. As her health did not materially 
suffer, she was deemed by some to be an impostor. 
During an attack of unusual severity of the neuralgia 
of the ear and face, accompanied by cerebral disturbance, 
a discharge suddenly occurred from her ear, which 
afforded some relief; it was, however, temporary, and 
the cerebral affection increasing, she died comatose. " 
In this instance again the Surgeon was prohibited from 
making a post-mortem examination. The case is not- 
withstanding interesting, as showing that sometimes the 
chronically diseased tympanum will excite neuralgia in 
the chorda tympani, or the tympanic plexus, which, ex- 
tending to the facial nerves, will simulate the symptoms 
of the painful face. 

The Writer has lately examined the right ear of Har- 
riet Mahoney, aged twelve years, which is affected with 
Otorrhea, the membrana tympani is removed by ulcera- 
tion, and granulations occupy the tympanic cavity, — 
the discharge is still fetid. The Author is informed that 
during the progress of the acute stage of the disease, the 



INTERNAL CHRONIC OTITIS. 



243 



child suffered from paralysis of the opposite side of the 
body, indicating pressure on the brain, which was after- 
wards removed. Probably the cerebral membranes, or 
the brain itself, were inflamed consecutively upon the 
Otitis, which terminated in serous effusion, which fluid 
afterwards became absorbed. (a) 

(a) The following case possesses interest in connexion with 
the present branch of inquiry. It is related by Mr. Roderick 
(London Lancet, 1839-1840, p. .239). 

" Miss , aged nine, a private patient of Mr. Callaway, 

had never been of a strong habit of body, but had in general 
enjoyed a good state of health, until the beginning of the year 
1835, when she became affected with scarlet fever, but soon 
recovered. Soon after convalescence, however, she became 
subject to deafness, with pain in the left ear, accompanied by a 
discharge of a thin purulent secretion of a foetid odour. An 
6 aurist' was consulted, who ordered an injection, probably of 
the sulphate of zinc, into the ear, with little benefit. 

" On Monday, the 19th of March, 1838, the pain in the ear 
became suddenly much more acute, and occupied a much larger 
portion of the side of the head than on former occasions. So 
extensive was the seat of this pain, that pressure applied to the 
mastoid process, caused a considerable aggravation of her suffer- 
ings. Pulse SO, and compressible. On the 20th the pain in the 
head was more severe, and occupied the greater part of the left 
side of the cranium. She also complained that the eyes were 
somewhat irritable, and that she could not bear the light of a 
candle. On the 22& the pupil of the right eye was observed to 
be somewhat larger than that of the left, though it was still 
obedient to the impression of light. There were, occasionally, 
convulsive movements of both the upper and lower extremities 
of the right side. During the intermission, however, of the 
latter, she possessed full power over both extremities. About 
nine o'clock on the evening of the 22d, she called for coffee, 
which being swallowed, was immediately vomited. The pulse 
was now 70 and rather laborious. She was perfectly sensible, 
and answered questions put to her. She continued sensible 
until nearly one o'clock, when she died. The head only was ex- 
amined after death. All the bones of the calvarium were remark- 
ably healthy, with the exception of the petrous portion of the left 
temporal, the anterior surface of which was of a reddish appear- 
ance, caused by increased vascularity, while a portion of the sur- 
face opposite the cerebellum was roughened from ulceration. 
On sawing through the petrous portion to expose the internal ear, 



244 CHRONIC DISEASES OF THE EAR. 

Mr. Liston possesses in his museum the three following 
preparations of morbid products connected with the tym- 
panum, two being- of great interest : — 

" Pars Petrosa of the temporal bone cut, exposing an 
abscess of the internal ear, with soft deposit to a slight 
extent. The patient, a female, aged eighteen, had for a 
long period profuse purulent discharge from the ear. The 
evacuation became suppressed, and violent headache, 
coma, and death ensued." 

" Pars Petrosa extensively broken up, and almost en- 
tirely covered by a soft medullary fungous tumour, which 
proceeds from (and has in all probability originated in) 
the cavities of the ear. The patient, a male, aged forty- 
seven, had been subject to severe headache, almost con- 

a quantity of pus was found in the latter, and the lining mem- 
brane was, in several plaees, destroyed by small ulcers. Both 
the cavity of the tympanum and the labyrinth had suffered from 
the disease ; there was also a cavity containing about a dram of 
foetid pus, within the mastoid process of the temporal bone. The 
dura mater was healthy, with the exception of a small portion 
which lay in contact with the diseased part of the petrous por- 
tion of the temporal bone ; and here it was externally coated 
with pus, somewhat thickened, and of a darker colour than 
natural. 

"The arachnoid was somewhat opaque in most places, but in 
the neighbourhood of the diseased bone the opposite portions 
were feebly adherent and coated with recently effused lymph. 
There was a large quantity of fluid infiltrated in the pia mater, 
and the vessels of this membrane were somewhat congested. 
The convolutions of the cerebrum were well developed. The 
cortical and cineritious portions were a little more vascular than 
in health ; each lateral ventricle of the brain contained about 
four drams of clear serum ; the left lobe of the cerebellum was 
so much destroyed by softening, that it formed one continuous 
cavity ; it contained, however, but a small quantity of pus. The 
portion of cerebellum surrounding this cavity was much injected, 
whilst the right lobe of the latter was healthy. The object of 
the narrator of the case was to ascertain whether any member 
had observed hemiplegia to be the result of abscess in the brain, 
caused or accompanied by disease of the bone ; he, Mr. Rode- 
rick, had never observed this to be the case ; in softening, how- 
ever, independent of disease in the osseous structure, he had 
known hemiplegia to be a frequent symptom." 



INTERNAL CHRONIC OTITIS. 



245 



slant for two or three years. Latterly the pain became 
more intense, accompanied with very considerable con- 
stitutional excitement. In this state he lingered for some 
days, and expired in great agony." 

" A tumour similar to the preceding. The patient, a 
middle aged woman, had long laboured under obscure 
head symptoms, accompanied with occasional purulent 
discharge from the ear. She was received into the me- 
dical ward of R. I., underwent a great variety of treat- 
ment without avail, and ultimately succumbed." 

The cases of medullary fungus exemplify the fact that 
the inner ear is liable to malignant disease as other struc- 
tures of the body. It may admit of question, however, 
whether these tumours originated in the ear, or extended 
to that organ from the brain, or the dura mater. Mr. 
Travers has reported a case of malignant disease impli- 
cating the internal ear ; but its exact connections he 
could not discover, a post-mortem examination not being 
allowed. 

Theory leads to the expectation, and experience con- 
firms its truth, that these serious evils extend in the ma- 
jority of instances from the tympanum to the brain ; yet 
it is very possible, and cases occur which seem to prove, 
that disease of the brain may extend to the tympanal 
cavity, and that by this means a cerebral or meningeal 
abscess may find an outlet. 

The Treatment of chronic Inflammation of the Tym- 
panum is conducted under great disadvantage, as the 
disease is often so insidious, as to be neglected until ex- 
tensive disorganization has taken place. Antiphlogistic 
remedies, modified by the circumstances of individual 
cases, are to be employed with a view of preventing the 
affection from extending; when'an Otorrhaea is established, 
experience has showm that it is a dangerous experiment 
to attempt its removal by powerful astringents, as a me- 
tastasis, or an extension of the disease to the brain, is so 
liable to take place ; it will therefore be more judicious 
to cleanse the auditory tube with the mildest applications ; 
to carefully avoid all excitement, and, for that purpose, 
to place a little cotton in the meatus, particularly when 
it is unusuallv exposed, and carefully to warn the patient 

31 



£46 CHRONIC DISEASES OF THE EAR. 

against introducing hard bodies to remove any accumu- 
lated matter. The general health is to be especially at- 
tended to ; and the signs of the disease extending to the 
brain should carefully be watched for, and on their very 
first appearance actively met by vigorous treatment. 

As the practitioner is not generally consulted upon 
such a case until after the accession of the cerebral symp- 
toms, it is very likely to be mistaken for idiopathic menin- 
gitis; a circumstance of much importance, as the conse- 
quential disease would not demand the depletory treatment 
to the same extent as an original affection would require ; 
and attention should be directed to restoring the otorrhsea 
which had previously existed, by means of warm fomen- 
tations, poultices, &c. 

In cases of chronic disease of the tympanum with an 
ulcerated membrane and mucus contained in the cavity, 
the Author has found great advantage from gently syring- 
ing it with warm water through the Eustachian tube, 
which, escaping by the external meatus, cleanses the tym- 
panum, and thus prevents the accumulation of pus in the 
cavity, which, becoming decomposed by the contact of 
air, may be a cause of inflammation ; and in many in- 
stances this proceeding is productive of great improvement 
in hearing. If the use of the syringe should occasion 
pain, it ought not to be repeated, without great caution ; 
on the contrary, if it give rise to a feeling of comfort in 
the ear, as well as an improvement in its function, it may 
be persevered in ; and even, perhaps, a slight stimulus 
may be sometimes used. With a similar view Dr. Burne 
has recommended the perforation of the mastoid cells, 
when the bone is not carious, that through the opening 
injections might be applied ; which must be more dan- 
gerous and less convenient than the former mode, and 
not more efficacious, as the fluid readily flows from the 
catheter through the tympanum into the mastoid cells. 

As one example of many, may be mentioned the case 
of Samuel Benyon, aged thirty-eight, who had fever in 
March, 1838, from which he recovered ; in April " he 
had a trickling sensation in both ears with tinnitus. This 
made him probe his ears with a pin, and in a day or two 



INTERNAL CHRONIC OTITIS. 



247 



afterwards they began to discharge considerably. In a 
fortnight more he nearly lost his hearing." In July the 
Author found him very deaf, and that he had once been 
considerably relieved by a discharge of matter and blood 
from the Eustachian tubes. Upon closing his mouth and 
blowing his nose in his handkerchief, the air whistled 
through both ears with a loud report ; upon inspection, 
a large opening was seen in each tympanic membrane. 
The catheter was passed with great facility into both 
Eustachian tubes, and warm water injected, which 
readily flowed into the meatus, mixed with muco-puru- 
lent matter ; it was immediately attended with consider- 
able improvement both in hearing and general sensa- 
tions. 

This proceeding is particularly applicable when mucus 
is accumulated in the tympanum, the membrane remain- 
ing entire ; the mucus being thus diluted, will more rea- 
dily flow through the Eustachian tube into the pharynx; 
or air may be injected with the same intention. (a) 

(a) M. Deleau gives a Table of the known lesions of the mid- 
dle ear which occasion deafness. 

FIRST CLASS. 

Affections of the f First Order. 

guttural orifice of Chronic inflammation, 
the Eustachian tube, <{ 

from disease of the I Second Order. 

pharynx. ^ Tumefied and indurated tonsils. 



Diseases of the 
Eustachian tube. 



SECOND CLASS. 

First Order. 
Simple obstruction. 

Second Order. 

«, • • n .. C without secretion. 

Chronic inflammation, 1 .,, 

J I with secretion. 



Third Order. 
Stricture situated in the 



C inner half, 
pouter half, 



248 



CHRONIC DISEASES OF THE EAR. 



Section V. 

CHRONIC INFLAMMATION OF THE EUSTACHIAN TUBE. 

Although the Eustachian Tube is implicated in the dis- 
eases of the tympanum, of which it forms a part, a few 
additional observations are necessary, inasmuch as this 
passage is liable to those affections which occur in other 
mucous canals. 



THIRD CLASS. 



Diseases of the j 
cavity of the tym-< 
panum. 



f First Order. 

Inflammation without secretion. 



Diseases of the 



Second Order. 

f from obstruction 
of the Eusta- 
Muculent accumulation <{ chian tube. 

I from increased 
[ secretion. 

FOURTH CLASS. 

f First Order. 

I Inflammation. 



membrana tympani. "j Secmd Qrder 

y Perforation. 



Complications at- 
tending disease of-< 
the middle ear. 



FIFTH CLASS. 

First Order. 
Combination of the above-mentioned affec- 
tions. 

Second Order. 
Diseases of the middle and of the external 
ear. 



Third Order. 
Diseases of the middle ear and of the laby- 
rinth, of the auditory nerves, and of 
the brain. 
— Rechevches Pratiques sur les Maladies de V Oreille, #c, p. 1 54. 



Tlate 75. 



Fig. I 




*& 






Fig.Z 






INFLAMMATION OF THE EUSTACHIAN TUBE. 



249 



Sometimes the mucous membrane of this tube is the 
seat of inflammation not extending to the tympanal 
cavity ; in which event it usually proceeds from a similar 
affection of the fauces, and not unfrequently of the tonsils. 
In this case the lining membrane being turgid, deafness 
is produced in consequence of the deficiency of renewed 
air in the tympanum ; an uneasy sensation is felt in the 
back of the throat, sometimes passing to the ear, which 
is relieved by a discharge of mucous from the tube. In 
ordinary cases this catarrhal affection soon subsides ; in 
other slight deafness continues, with an excitable condi- 
tion of the membrane, which is always relieved when a 
discharge occurs, and thus the anomaly may be accounted 
for, that in some of these instances a slight coal increases 
the power of hearing, by giving rise to a secretion, and a 
consequent lessening of the tumefied membrane ; in the 
greater number of cases, however, such increased action 
augments the symptoms, by diminishing the calibre of 
the tube. 

The Stricture of the Eustachian Tube is a consequence 
either of acute or chronic inflammation. This term is 
often applied to every partial as well as complete closure 
of the canal. It frequently happens that a small quan- 
tity of air may be admitted into the tympanum, though 
insufficient for the purposes of its function ; the patient 
is under these circumstances more or less deaf, and if the 
contraction of the tube has come on gradually, as often is 
the case, it may not even be suspected. In these instances 
the Surgeon must deduce his diagnosis from negative 
symptoms, as the absence of disease elsewhere, and the 



PLATE XV. 

Fig. 1. — An internal view of the Inferior chamber of the Nose, 
with the mouth of the Eustachian tube, into which 
a probe is passed. 

Fig. 2. — A section of the Face, showing the right side of the 
septum of the Nose, the hard and soft palates with 
the Uvula ; and the orifice of the left Eustachian tube, 
with a probe passed through it. 



250 CHRONIC DISEASES OF THE EAR. 

healthy condition of the meatus and membrane of the 
tympanum, and by the impossibility of the patient forc- 
ing air through the tube in a powerful expiration with 
the mouth and nostrils closed, which will be evidenced 
by the want of a crackling sensation in the ear, and the 
incapability of the Surgeon hearing the air rush into the 
tympanum, or striking against its membrane, either by 
the aid of the stethoscope, or with his ear in contact with 
his patient's. The detection of such alteration in the 
tube is reduced almost to a certainty, by exploring the 
canal with a sound or catheter, by which it becomes as 
distinguishable as a stricture situated in the urethra. The 
deposition causing stricture more frequently arises from 
scarlet fever or small-pox affecting the fauces, and with 
them the mouths of the tubes, than from other causes : 
common catarrh, cynanche tonsillaris, and particularly 
the spreading of a venereal sore of the throat will often 
produce this effect ; the causes are so frequently and so 
directly applied, that it is rather astonishing that this 
consequence is not more common than it is found to be; 
yet it is certain that the occurrence is not rare, and is 
very often overlooked. 

A gentleman, who had been deaf for several years, in 
consequence of frequent colds, applied to the Author ; he 
had no uneasiness, but his hearing was so defective, as to 
render his life almost a burden to himself; he had applied 
to several so-styled aurists, who had prescribed lotions 
for the meatus, blisters, &c, without benefit. Upon ex- 
amination, the outer ear, with the tympanal membrane, 
was found to be perfectly healthy ; he could with diffi- 
culty force a little air into the tympanum by powerful 
expiration, the nose and mouth being closed. Upon pass- 
ing the catheter into the Eustachian tube, it was clearly 
shown to be narrowed ; air, and afterwards warm water, 
were with some little difficulty passed through the instru- 
ment, but gave rise to the customary uneasy sensation in 
the tympanum : when the catheter had been introduced 
several times, it readily passed nearly to the cavity, and 
while it remained in, and air was admitted through it, 
the hearing was improved, and continued so for several 
hours, and sometimes a day or two, when the tube gra- 



INFLAMMATION OF THE EUSTACHIAN TUBE. 25 1 

dually regained its abnormal contraction. The patient 
has frequent attacks of catarrh, in consequence of his 
habits and predispositions, which materially interfere with 
the treatment ; he has now for a time been obliged to 
defer the plan proposed, that, namely, of dilating the tube 
by mechanical means, and therefore the effects of the 
treatment cannot be further stated ; the prospects of suc- 
cess are, however, encouraging. 

The Author frequently sees Jane Edwards, about thirty 
years old, who has been inconveniently deaf for some 
years, in consequence of a sore throat while labouring 
under small-pox • she has several times, with an interval 
of some weeks, and occasionally two or three months, ex- 
pectorated some very disagreeable mawkish matter, which 
gives her the sensation of proceeding " from the back of 
the throat, high up ;" and she believes it to come from 
the ear, as she always hears better for some time after- 
wards. She can with difficulty, and that only occasion- 
ally, force air into the tympanum. Her auditory canal 
and membrane are quite healthy. The catheter was 
passed most readily into the tube, without giving rise to 
the least pain, or occasioning the loss of a drop of blood; 
she thought she heard better while the instrument was 
in the canal, and felt the air, and afterwards the water, 
which were injected into the tympanum ; and she left 
the Writer with full hopes of obtaining relief. In about 
five minutes, upon blowing her nose rather violently, the 
integument of the cheek became suddenly emphysema- 
tous, which extended down the neck, producing an ap- 
pearance something resembling the goitre; it reached 
the thorax and abdomen, and both upper extremities 
were especially distended and stiff; the respiration was 
somewhat interfered with, and deglutition for a few hours 
impracticable. This emphysema continued for several 
days, when the air was gradual^ absorbed, leaving no 
inconvenience. It occurred to the Author that an old 
cicatrix in the immediate vicinity of the mouth of the tube 
must have been broken by the catheter, notwithstanding 
the instrument passed with unusual facility, and that 
the air forced into the exposed cellular tissue by expira- 



252 CHRONIC DISEASES OF THE EAR. • 

tion in blowing the nose, and which subsequently escaped 
in breathing, extra vasated in the manner described. The 
unpleasant, and even alarming effect produced in this 
case, illustrate the necessity of the practitioner observing 
the greatest care and delicacy in the introduction of the 
Eustachian tube catheter. 

Upon catheterizing the Eustachian tube of Mrs. El- 
dridge, who, with a healthy external ear, had been long 
deaf in consequence of small-pox affecting her throat, a 
slight impediment to the passage of the instrument sud- 
denly gave way and her hearing was immediately im- 
proved ; of course, frequent repetition will be required 
to ensure permanent perviousness of the canal. 

Mr. D., a medical student, had been frequently the 
subject of inflammation of the tonsils and fauces generally, 
which attacks were attended with severe pain, particu- 
larly extending through the ears, and which occasioned 
deafness, increasing after each affection. The Author 
saw him during one of these attacks, when the agony, 
which nearly induced delirium, was relieved by antiphlo- 
gistic remedies, including free leeching, directed to the 
throat; it was anticipated that the cause of deafness would 
require after-treatment. Another inflammatory affection, 
some months subsequently, while the patient was in the 
country, left him perfectly deaf on one side, with " a sen- 
sation of some discharge passing from the Eustachian 
tube into the pharynx, and causing a constant inclina- 
tion to swallow and cough." Many remedies were re- 
sorted to unsuccessfully. On his return to town in March 
last, the Author again saw him, and upon introducing 
the catheter into the affected Eustachian tube, he felt an 
impediment, as though a band crossed the canal, which 
gave way to slight pressure, w T hen the instrument passed 
as far as usual. The patient's hearing was immediately 
so perfectly restored, that it was considered unnecessary 
to adopt any further treatment. 

A gentleman of general good health, but of a nervous 
temperament, had been deaf nearly thirty years, the re- 



INFLAMMATION OF THE EUSTACHIAN TUBE. 



253 



suit of an inflammatory affection of the throat ; he could 
not force air through the Eustachian tubes; the left 
meatus and membrane were healthy ; the right membrane 
to a slight degree chronically inflamed, the consequence, 
most probably, of irritating applications. The catheter 
readily entered the mouths of the tubes, but required a 
little force to effect the complete introduction, when air, 
and afterwards warm water, were, with a little difficulty, 
thrown into the tympanic cavity. Whilst the instruments 
remained in the tubes, the capability of hearing w r as 
much increased. The occasional dilatation has rendered 
the canals so pervious, that the patient can readily inflate 
the tympana, but the faculty of hearing is not propor- 
tionately restored in consequence of the torpid condition 
of the acoustic nerve, depending probably on its long 
partial disuse, (a) 



(a) Mr. Neil {Report of the Liverpool Eye and Ear Infir- 
mary, in Med. Gaz.,Oct. 1841) expresses an opinion entirely coin- 
cident with that given in notes to pp. 177 and 1S5. He says: "the 
most frequent cause of deafness is inflammation and thickening 
of the lining membrane of the Eustachian tube, and obstructions 
from morbid secretions ; and it is in such cases that the air-press 
is useful. Granulation, too, similar to the granulated eyelid, 
will frequently be found to exist, and is an aggravated state of 
chronic inflammation of the mucous membrane in a strumous 
habit." 

Mr. Pilcher does not direct attention in an adequate manner to 
the constitutional treatment of chronic inflammation of the Eus- 
tachian tube and its consequences. The views entertained on 
this point by Mr. Neil, are, we believe, those of the most intelli- 
gent physicians and surgeons. In reply to the question, — "In 
what cases do you recommend constitutional treatment, and in 
what does such constitutional treatment consist ?" 

Mr. Neil answers: — "When there is a strawberry-looking 
tongue, a relaxed uvula, enlarged tonsils, enlargement of the 
glands of the neck, thickening of the lining membrane of the 
Eustachian tubes, an irritable state of the lining membrane of the 
nostrils, a strumous habit, and, also, when there is an irritable 
state of the mucous membranes, I should expect that constitutional 
treatment would benefit my patient, and assist the mechanical 
process which I might consider right to use ; and my constitutional 
treatment would consist in blue pill, sedatives, antacids, iodine in 

32 ' 



254 



CHRONIC DISEASES OF THE EAR. 



Sometimes the parietes of the Eustachian tube are so 
firmly adherent as not to admit the smallest instrument, 
nor the least portion of air ; in which case the patient is 
perfectly deaf of that ear, excepting so far as the sounds 
may be conveyed through the cranial bones. Such an 
impervious stricture occasionally occurs from the cicatri- 
zation of a specific ulcer, as that following scarlet fever, 
small-pox, and particularly syphilis. Many cases of this 
kind are recorded, and several of great interest by Sir A. 
Cooper in the Philosophical Transactions. 

The Treatment of Stricture of the Eustachian Tube 
has of late years been much improved, since the import- 
ant introduction into practice of catheterism of this canal. 
There are many cases in which the obstruction is so firm 
as to render this operation quite abortive ; but the Author 
does not hesitate to declare his belief that very many of 
the so-called incurable strictures will yield to cautious 
and regular dilatation. "When Sir A. Cooper introduced | 
his operation of puncturing the membrane of the tym- 
panum, he was not aware of this procedure ; and no doubt 
can exist, that in many instances in which the membrane 
was punctured, and in several which this distinguished 
Surgeon has related, the obstruction might have been 
removed : and particularly this observation may be ap- 
plied to those cases where there is a collection of mucus 
or blood in the cavity, which may be more easily syringed 
out with warm water through the tube, than removed 
through an artificial opening in the membrane. 

Catheterism of the Eustachian Tube is required for 
several purposes : — 1st. As an important means of inves- 
tigating its condition of health or disease, and that of the 
tympanum — 2d. To remove mucus or blood from the 
tympanal cavity — 3d. To dilate a stricture of the tube 
— and, 4th. To stimulate the nervous system of the ear 
in cases of diminished function. 



some of its forms, and afterwards tonic medicines. First I would 
awaken a new and healthy action in the mucous membranes ; 
and, next, I would endeavour to excite the nervous energy of 
those and of the contiguous parts." 



TlaZe 76. 



Tig/ 




INFLAMMATION OF THE EUSTACHIAN TUBE. 



255 



The catheter used by Itard is a conical silver tube, 
curved at the extremity, with a slight enlargement, to 
prevent it lacerating the membrane (Plate XVI., fig. 3). 
This instrument is easily introduced, but can be passed 
only to a short distance into the tube, and therefore is 
useless as a sound. Kramer has modified Itard's cathe- 
ter, by making the curve more gradual, and omitting the 
button point (XVL, fig. 4). Both authors propose to 
sound the tube by means of catgut run through the in- 
strument ; for which purpose, and particularly to inject 
fluids into the tympanum, it is necessary to fix the cathe- 
ter by a frontal bandage, which is furnished with a pair 
of strong holders or forceps. The Author, when he first 
practised this operation, was desirous to dilate a con- 
tracted tube, and therefore gave to his instrument a longer 
and more gradual curve ; the bend near the handle allows 
it to rest more conveniently against the tip of the nose. 
This shape was determined upon, after trying a wire, 
bent in various degrees, upon a preparation of a perpen- 
dicular section of the head and face, when that depicted 
in the sketch (Plate XVI., fig. 5) was found to enter the 
tube, and to run along nearly an inch of its extent with 
great ease. A graduated silver wire stylette is also ap- 
pended to it, which may be introduced beyond the 
catheter if the Surgeon should deem it advisable, or a 
catgut string may be used, which, at the same time that 
it is safer, will answer the purpose as well; and the 



PLATE XVI. 

Fig. 1. — Speculum auris used by Kramer. 

Fig. 2. — Speculum auris used by Deleau and Itard, and gene- 
rally adopted in this country (England). 

Fig. 3. — Itard's Catheter for the Eustachian Tube. 

Fig. 4. — Kramer's Catheter, which is made of various sizes for 
subjects of different ages. 

Figs. 5, 6, and 7. — The Author's Catheters of various lengths 
(one with a Stylette of Whalebone passed through it). 



256 CHRONIC DISEASES OF THE EAR. 

Author has lately used stylettes of whalebone, slightly 
enlarged at the point, which he finds much more con- 
venient and useful than when made of other material. 

The mode of passing either catheter is nearly the same ; 
the instrument being warmed and slightly oiled, is 
passed along the floor of the nostril till the point reaches 
the pharynx, with the convexity upwards, and the con- 
cavity downwards ; it is then gently turned, so that the 
point shall be outwards and a little upwards, the mouth 
of the Eustachian tube being above the level of the floor 
of the nose ; the Surgeon readily feels when the catheter 
slips over the orifice of the canal. The instrument is then 
to be gradually carried onwards, until opposed by the 
narrowing of the tube; in the adult it will frequently 
occupy three-quarters of an inch of the canal ; if the 
catheter should be forced beyond the fibro-cartilaginous 
portion, or that part of the tube which readily admits it, 
the mucous membrane may be lacerated, and pain will 
certainly be produced. When the instrument is fairly 
introduced, it will remain without support, by which it 
possesses considerable advantage over the catheters of 
Itard and Kramer. As the only difficulty in passing 
the Eustachian tube catheter consists in turning the 
point upwards to enter the canal, the Author generally 
obviates it by carrying the instrument along the inferior 
meatus of the nose, in the channel formed by the inferior 
turbinated bone, and the external and inferior walls of 
the nostril, which may readily be effected without risk of 
striking the mouth of the lachrymal canal; he directs 
the catheter obliquely, so that its convexity is upwards 
and inwards, and its concavity downwards and outwards, 
hence the necessary rotation is considerably diminished. 
When used for the purpose of investigation, the wire may 
be carried further onwards, or what will be much safer, 
the catgut or whalebone sound may be passed through 
the catheter. If it should reach the tympanal cavity, it 
will give rise to pain, often severe, to a loud cracking 
noisy sensation, extending to the mastoid cells ; these 
feelings will be the more marked in proportion to the 
healthy state of the tympanum. The Surgeon must be 
especially careful not to injure the ossicula, the avoidance 



CATHETERISM OF THE EUSTACHIAN TUBE. 



257 



of which will require great caution, passing as they do 
across the cavity ; the stylette must therefore just reach 
the tympanum, without entering it. If the membrane 
and ossicula are lost, the same caution will not be needed, 
but in such a case sounding will rarely be required. 
When air or warm water is injected into the tympanum, 
sensations similar to those mentioned are produced : and 
the air may be heard to strike against the surface of the 
membrane, and to rush through the cavity into the mas- 
toid cells, (a) 



(a) Mr. Neil's directions for the introduction of the catheter 
into the Eustachian tube are as follows : — " Take No. 8 catheter, 
as made by Weiss, of the Strand, London ; the No. 8 Kramer 
catheter ; it is the one I almost invariably use : stand on the right 
side of the patient, whose left side should touch a table, on which 
is the air-press. Stand comfortably on the right side, and put 
your left hand on the top of the patient's head ; hold the catheter 
between the thumb and middle ringer of the right hand — hold 
it so near to the end at which the loop is, that the fore-finger 
will touch the open end of the tube : then introduce the beak of 
the instrument into the nose very quietly. Your hand should 
be as low as, or a little lower than, the patient's mouth, during 
the stage of the operation ; as you continue advancing the point 
of the instrument along the very floor of the nostril, continue 
gently raising the hand, until, when the back of the instrument 
touches the back part of the throat, your hand shall be as high as 
the top of the nose, and the catheter itself will be at the upper 
edge of the nostril. You may then rest for a moment, and it is 
a good opportunity to chat to those around you, so as to remove 
any fear from the mind of the patient ; he also gets accustomed 
to the sensation of the instrument in the nose, and will allow 
you to accomplish the operation easily. You will now bring 
your left hand round the patient's head, so as to have it in rea- 
diness to grasp the catheter when it is rotated into the Eustachian 
tube, that it may be gently and safely held for the introduction 
of the air. You will now again take hold of the catheter, touch 
the back of the throat with it, to be certain that it has reached 
its destination ; then endeavour to make it rotate upwards, draw- 
ing it gently forwards until you accomplish this object, which is 
much facilitated by desiring the patient to swallow ; he, in that 
act, raises the pendulous palate, and removes all obstruction to 
the entrance of the instrument. I take advantage of this motion 
always, to pitch in the catheter ; when in, in most cases, it will 



258 



CHRONIC DISEASES OF THE EAR. 



Deleau introduced the air-douche for the purpose of 
removing matter from the cavity, and also distending the 
contracted tube, which Kramer considers a great improve- 
ment upon the injection of fluids. Both these intelligent 
aurists used an air-press for the purpose of increasing and 
regulating the force employed. The Author, however, 
daily experiencing the great facility with which air and 
fluids may be introduced into the tympanum, and regu- 
lated both as to quantity and force, by means of a com- 
mon syringe accurately fitted to the catheter, does not 
hesitate to declare his conviction that the ceremony and 
inconvenience of the air-press may be dispensed with. 
It is of course requisite that the operator should steady 
the instrument with his left hand while using the syringe 
with his right. By this means any fluid or gas may be 
brought into contact with the mucous membrane, and 
thus stimulate the nerves of the cavity. Deleau uses a 
flexible catheter, but it does not appear to have any ad- 
vantage over the silver instrument, and is more inconve- 
nient in introduction. Catheterism will be necessarily 
often repeated, and continued for many minutes at each 
time, for the purpose of fulfilling the intentions above 
stated. 

This important operation was first performed by Guyot, 
a Post-master at Versailles, about a century ago, upon 
himself, and he succeeded in improving his deafness, 
though he passed the instrument through his mouth. It 
is believed, however, that Guyot did not introduce a ca- 
theter, but merely scraped the orifice of the tube with some 
firm body. Itard revived the operation, and very mate- 
rially improved it. It cannot be requisite to allude to 
the impracticability of effectually passing an instrument 
into the Eustachian tube through the mouth, as it is well 
known that the velum prevents it ; whereas, a little expe- 

remain if left alone in the passage ; and the loop on the outer 
part of the catheter denotes that the corresponding concave side 
has its beak also pointed outwards. 

" There is no use in having the catheter graduated, unless you 
could have all men's faces of the same depth. I do the whole 
process myself; and never allow any one to assist me." — Ibid. 



PUNCTURING OF THE EUSTACHIAN TUBE. 



259 



rience renders its introduction through the nose one of 
the easiest of the minor operations in Surgery. 

In 1800, Sir A. Cooper introduced the operation of 
'puncturing the membrana tympani. The suggestion oc- 
curred to his acute mind, that as a large aperture produced 
by disease or accident, in itself, hardly interfered with 
hearing, a small puncture skilfully performed would be 
unattended with inconvenience ; and the successful re- 
sults justified his anticipations. 

The operation was immediately tried by many others, 
but not uniformly with similar success; which is to 
be attributed to the great eclat produced by the innova- 
tion inducing many practitioners to employ it in cases 
where it was inadmissible. The operation is now super- 
seded in many instances in which it was originally used 
by the catheterism of the Eustachian tube, and appears to 
be only absolutely necessary in invincible stricture of 
that canal. Riolanus proposed this procedure long before 
Cooper, a circumstance, however, of which the latter 
gentleman was not aware. The operation is easily per- 
formed by having a strong light directed upon the mem- 
brane, which is then to be perforated at the lower part, 
anterior to the inferior extremity of the manubrium of the 
malleus. This is readily accomplished with a small per- 
forator, having a sharpened point extending two or three 
lines beyond the shoulder. For the sake of security a 
small trocar and canula have been used, the trocar being 
capable of projecting only the requisite distance beyond 
the canula ; the sheathed instrument is carried against 
the membrane, and, then suddenly thrust through. The 
chief objection to this operation is the readiness with 
which the wound heals, in consequence of which its re- 
petition is rendered necessary. In order to obviate this 
defect, Mr. Buchanan recommends a quadrangular per- 
forator, which, by making a larger opening, will render 
the wound less likely to close. Hirnly has introduced 
for the same purpose a little punch, which cuts out a 
small round piece, somewhat similar to the shoemaker's 
punch, which instrument Dr. Kramer infinitely prefers. 
Hemorrhage, which occasionally fills the tympanal cavity 
with blood, is another inconvenience arising from the 






260 



CHRONIC DISEASES OF THE EAR. 



perforation, — in most of such cases the blood has even- 
tually escaped through the opening; yet, there is danger 
of its becoming organized, or remaining there in a clot, 
and so producing deafness. (a) 



(a) The accidents which sometimes occur in consequence of 
catheterism of the Eustachian tube, and injections of air into the 
middle ear, are described by M. Deleau under the following 
heads : — 1. Inflammation of the throat, and catarrh of the tym- 
panum. 2. Emphysema. 3. Rupture of the membrana tym- 
pani. Emphysema has occurred to Deleau six or seven times. 

It is probable that the deaths recorded within a year or two 
past in the London Medical Journals, as following the pumping 
of air from a press into the Eustachian tube, were really owing 
to its passage into the larynx, by the catheter taking a wrong 
direction and not having penetrated at all into the tube. 

The importance, and, in a great degree, the novelty of the 
subject in this country, will justify the introduction of the follow- 
ing Clinical Observations by Mr. Wharton Jones, on the Use of 
the Air-Douche in the Diagnosis and Treatment of Diseases of 
the Ear. (Lond. Med. Gaz. 1839.) 

No. I. — Circumstances having of late forcibly drawn the at- 
tention of the profession to catheterism of the Eustachian tube, 
and injections of atmospherical air into the tympanum, it behoves 
every one to contribute what mite of information he may pos- 
sess, at all calculated to clear away the difficulties or doubts 
which hang about the subject; for, like most new modes of 
treatment, considerable misconception prevails regarding it, both 
as to the principle and performance of the operation, as well as 
its advantages, — being on the one hand overrated, and on the 
other underrated. 

Carefully observed and faithfully reported cases, it is obvious, 
are the only means of guiding to a correct judgment. Many 
cases are to be found in the works of Deleau and Kramer, but 
they do not record the daily progress of the treatment ; for this 
reason I have thought the following cases, extracted nearly word 
for word as they occur in my case-book, might be read not with- 
out interest. And here I would express a hope that these con- 
tributions will be received as they are offered — viz., as imper- 
fect observations on a subject not, indeed, of easy investigation, 
but by no means incapable of it — a subject which, it is hoped, 
surgeons will see the propriety of attending to more than hitherto, 
so as to be able to discriminate what can from what cannot be 
done, and what it is safe from what it is unsafe to do. In all 
this we must keep in mind the precept — "Nil fingendum, nil 



CLINICAL OBSERVATIONS. 261 

excogitandum, sed inveniendum quod natura ferat — quod natura 
faciat." 

It is to be premised, that we endeavour to form our diagnosis 
of the state of the Eustachian tube and cavity of the tympanum 
on the principle already adopted in diseases of the chest — viz., 
to hear, when it is impossible to see or touch the disease ; the 
only difference being, that the air producing the sounds in the 
tympanum is put into motion artificially by the air-douche. 

In regard to the air-douche as a means of treatment, all that 
can be effected by it is the gradual dispersion of any accumula- 
tion of mucus which may exist in the middle ear/o*r the render- 
ing pervious the Eustachian tube, the walls of which have been 
glued together by thickened mucus. 

The eye and ear, though apparently so very different from 
each other, coincide in many respects both in their structure and 
in their diseases. As the diseases of the former are much better 
known than those of the latter, the cautious use of this analogy 
will be of material service in our examination of the morbid 
conditions of the ear. Thus, for the sake of example, it may 
be mentioned that the conjunctiva, that part of the eye which is 
the seat of some of its most important diseases, is a mucous 
membrane situated at the peripheral surface of the eyeball. In 
the ear, some of the most common causes of the derangement of 
its function depend, in like manner, on the morbid condition of 
a mucous membrane — that lining the cavity of the tympanum — 
which, being situated at the peripheral surface of the labyrinth, 
the essential part of the apparatus of hearing, bears exactly the 
same anatomical relation to it as the conjunctiva does to the 
eyeball. Again, the nasal duct, a mucous canal, is the seat of 
some not unfrequent and very troublesome affections of the eye. 
The Eustachian tube, which resembles the nasal duct in every 
anatomical particular, does so also in a remarkable degree in its 
pathological states. Many more examples might be given of 
the similarity between the structure and diseases of the eye and 
ear, but these are sufficient to direct attention to the fact. It is 
to be borne in mind, however, that in consequence of the dif- 
ference of conditions required for the exercise of the functions of 
the two organs, the same elementary form of disease shall have 
a very different effect on vision and hearing. For example, in- 
flammation and obstruction of the nasal duct has not such a 
direct effect on the exercise of the function of the eye as the same 
state of the Eustachian tube has on that of the ear. 

In the case of the eye, we can readily remove any accumula- 
tion of thickened mucus by means of a sponge and warm water; 
but the more inaccessible cavity of the tympanum requires to be 
cleared out by more complicated means. In applying the air- 
douche for this purpose, or for the purpose of diagnosis, we 

33 



262 CHRONIC DISEASES OF THE EAR. 

ought to go on much the same principle as is followed when it 
is wanted to blow dust, &c, out of the pipe of a key — viz., give 
free room for the regurgitation of the air, both where the catheter 
is inserted into the mouth of the Eustachian tube, and where the 
nozzle of the tube of the air-press is inserted into the dilated end 
of the catheter. 

But as in catarrhal ophthalmia, for instance, it is not enough 
to wipe away the discharge from the eye, but also necessary to 
make some local application to the conjunctiva, if not to employ 
some general remedy ; so in many cases we must medicate the 
membrane lining the cavity of the tympanum at least (if we do 
not think it necessary to adopt any more general treatment), 
after the accumulated mucus has been removed by the air- 
douche ; or in the event of no accumulation existing, there may 
still be a morbid state of the membrane lining the cavity of the 
tympanum, admitting of being as beneficially acted upon by 
some local stimulating application as the conjunctiva in chronic 
conjunctivitis. 

It is as simple a matter to put a drop into the eye as to wipe 
away a discharge ; but in the case of the ear, it is as complicated 
a proceeding to apply a remedy directly to the membrane lining 
the cavity of the tympanum as to disperse accumulated mucus. 
Watery injections are inconvenient in their application, and 
cause pain. The vapour of acetic ether, admitting of being 
easily sent in, and exciting no pain beyond a prickling sensation, 
has been found the best adapted. 

The cases which derive advantage from the injection of 
ethereal vapour, Dr. Kramer considers cases of nervous deafness ; 
but I believe some change in the membrane lining the tympanum, 
will, in many instances, be found a more likely cause of the 
symptoms than any affection of the auditory nerves, as well as 
the more likely condition to be benefited by the contact of the 
vapours of acetic ether. 

We have, as yet, no correct knowledge of the diseases of the 
labyrinth. A correct diagnosis, as far as may be, having been 
formed, of course it is advisable to employ, before or in addition 
to purely local treatment, leeching, blistering, or whatever other 
more general remedies may be indicated, the same principles 
that guide in the employment of general treatment in diseases of 
the eye, &c, guiding us here. 

To place in a striking point of view how far the air-douche 
serves as a means of diagnosis, and how far as a means of treat- 
ment, I take the following calculation from Dr. Kramer's " Tabu- 
lar view of the frequency and curability of diseases of the ear," 
remarking that it corresponds with my own, though less exten- 
sive, experience here. Out of 300 cases of diseases of the ear of 
all kinds, 200 in round numbers require the air-douche to assist 



CLINICAL OBSERVATIONS. 



263 



the diagnosis, but abotit 30 only are curable by it. Of the re- 
maining 170, about 30 are put down as cured, and about 50 as 
relieved, by the injection of vapours of acetic ether ; this treat- 
ment having been continued for months. Of the remainder, 80 
were considered as incurable from the first, and not treated 
(farther than the exploratory treatment, I suppose) : the rest re- 
mained rebellious to treatment. 

As, in the following cases, admeasurement of the hearing 
distance by a watch is constantly referred to, it may be well to 
remark, that the capability of catching conversation is not always 
in proportion to the power of hearing a definite and equable 
sound, like that of a watch. The power to follow conversation, 
is, in fact, sometimes greater than we might suppose indicated 
by the distance at which a watch is heard ; but, on the other 
hand, it is also sometimes considerably less, and this I have par- 
cularly remarked in cases treated, and so far improved, by the 
injection of vapours of acetic ether. Notwithstanding this, an 
approximate conclusion regarding the state of the hearing, suffi- 
cient to regulate our diagnosis and treatment, can be made by 
means of the ticking of a watch, particularly as the sound can 
be admitted to the ear under examination, always under similar 
circumstances. 

Case I. — Accumulation of Wax in external Auditory Passages. — Obstruction 
of Eustachian Tubes. — Cavity of the Tympanum free. 

A. B., a woman-servant, aged 40. 

Wednesday, August 8, 1838. — Left ear: Hearing distance 
by a watch, two inches, with noise in the ear sometimes like a 
waterfall. 

A year last January, the affection came on for the first time, 
in consequence of cold. The deafness continued for about six 
weeks, and then went off suddenly. About the end of the fol- 
lowing summer the deafness came on again, and then went off 
as before. Was attacked again in the following winter, but that 
time the deafness and noise in ear continued three months. The 
present attack has continued six weeks. 

Right ear. — Hears the same watch at a distance of nine feet, 
ten inches. Had noise in the right ear last year, but not now. 
The right ear was as bad as the left when first attacked. 

Throat a little red, but not swollen. Sense of smell not so 
acute as formerly, and nostrils rather dry. 

Considerable accumulation of dark-brown wax in both audi- 
tory passages. 

Wax ordered to be syringed out, preparatory to further exa- 
mination. 

Thursday, 9th. — Has had both ears syringed out. The pas- 



264 CHRONIC DISEASES OF THE EAR. 

sage on the right side is now quite clean, and free from any ac- 
cumulation of wax ; but the lower wall, about the middle, has 
been fretted by the point of the syringe. The membrana tym- 
pani on this (right) side, is opaque and slightly yellow ; the han- 
dle of the malleus, however, can be distinctly seen. 

Still some wax in the left passage, so that only the lower part 
of the membrana tympani can be seen ; and this part appears to 
be in the same state as the membrane is on the right side. 

Noise in the left ear entirely gone, but still feels stuffed. 

Hearing distance of the right ear, fifteen feet, seven inches -, 
of the left ear, fifteen feet, four inches. 

Ordered the left ear to be syringed again, and a solution of 
the Acetate of Lead (gr. iij. Aq. dest. .?j.) to be poured into the 
auditory passages two or three times a-day. 

Friday, 10th. — Hearing distance of right ear, thirteen feet, 
nine inches ; of left ear, nine feet, six inches. 

Still some wax in left auditory passage, which was ordered to 
be syringed out again. 

A feeling of stuffing, in both ears, proceeding from the nose, 
as if she could not breathe. 

Applied the air-douche to the left side, and found that the air 
did not penetrate to the tympanum. 

To take a little medicine. 

Saturday, 11th. — Still some wax adhering to the upper wall 
of the left auditory passage, but the whole of the membrana tym- 
pani can be seen. Has had some noise in the left ear like the 
singing of a tea-kettle. 

Hearing distance of the right ear 10§ feet; of the left ear, 14 
feet, 9 inches. 

Applied the air-douche again to the left ear, but the air did not 
penetrate. Applied the air-douche also to the right ear. The 
air penetrated at first in a small whistling stream, and then with 
some gurgling, but yet not very freely. Stuffing on the right 
side a little relieved, but still exists on the left side. 

The right ear heard the watch, after the application of the air- 
douche, at the distance of 17 feet, 9 inches ; the left ear at 1 1 feet, 
10 inches. 

Monday, 13th. — Left auditory passage is now quite clear. 
Still some noise in left ear like the ticking of a watch, but not 
constant. 

Applied the air-douche to the left ear. The air now pene- 
trated a little, so that the sensation of stuffing is somewhat less. 
Applied the air-douche to the right ear also, when the air en- 
tered more freely than on Saturday, and with a rushing and 
gurgling sound. 

Hearing distance of the right ear is now 18 feet, 4 inches ; 
that of the left ear is 1 9 feet, 9 inches. 



CLINICAL OBSERVATIONS. 



265 



Tuesday, 14th. — The right ear just hears the watch from one 
corner of the room to the other (about 25 feet). No stuffing. 

Left ear. — Stuffing less ; still some noise like the ticking of a 
watch occasionally. Just hears the watch from one corner of the 
room to the other. 

Applied the air-douche to the left ear only to-day. The air 
now enters freely with a rushing and howling sound. After 
the douche, no noise in the ear, nor feeling of stuffing.. The 
heaviness and confusion of the head which she had formerly are 
now gone. About five minutes after the application of the air- 
douche, heard the watch with the left ear pretty distinctly from 
one corner of the room to the other. 

Wednesday, 15th. — Has had no noise in the left ear since 
yesterday. Stuffing very much less. No stuffing in the right 
ear. Throat and tongue pretty well. 

Hears the watch distinctly with both ears from one corner of 
the room to the other. 

To come again on Friday. 

Friday, 17th. — Noise in the ears recurred this morning, toge- 
ther with the sensation of stuffing. 

Right ear 14 feet, 8 inches ; left ear 16 feet. 

Applied the air-douche to both sides. There was some gur- 
gling heard in the right tympanum. Some stinging pain felt, 
more on the right side than on the left, when the air is sent in 
with any degree of force. 

After the douche, heard the watch from one corner of the room 
to the other, but less distinctly with the right ear than with the 
left. Noise and stuffing gone. 

Saturday, 18th. — No complaint, and hears well. Dismissed, 
cured. 

Remarks. — Though a simple, this is a very valuable and in- 
structive case ; and as such, I have chosen it to begin with. 

The first thing to be noted is, the coincident accumulations of 
wax in the external auditory passages, with obstruction of the 
Eustachian tubes, complete on the left side, and incomplete on 
the right — circumstances indicating the previous existence of 
erythematous inflammation of the external auditory passages, and 
a catarrhal affection of the mucous membrane of the middle ear. 

Though the right and the left auditory passages were equally 
stopped up with wax, the Eustachian tube of the right side was 
not completely obstructed ; hence, perhaps, the cause of the dif- 
ference in the power of hearing presented by the two ears before 
the removal of the wax. 

But the circumstance which merits particular notice, and 
which, according to prevailing notions of the physiology of the 
ear, was not to have been expected, is the great increase of the 
hearing distance after the removal of the wax, notwithstanding 



266 



CHRONIC DISEASES OF THE EAR. 



the existence of obstruction of the Eustachian tubes discovered 
by the application of the air-douche — obstruction so complete 
on the left side as not to yield to the air-douche until the third 
sitting. 

The obstruction of the Eustachian tubes appeared to be owing 
to a glueing together of their walls by thickened mucus. The 
sounds produced by the entrance of the air indicated a pretty 
natural state of the cavity of the tympanum ; hence the rapid 
improvement in hearing consequent on the removal of the wax, 
even while the Eustachian tubes remained obstructed, and the 
still further and equally rapid improvement, according as the 
latter were rendered pervious. 

No. II. In the case which I related last week, the increase of 
the hearing power manifested from day to day was a warranty 
to persevere in the same treatment, until improvement should, 
under its influence, go no further, or until the cure should be 
complete. The result was, that the hearing rose to the common 
natural standard ; the means of diagnosis becoming at the same 
time the means of cure. In the following case, the treatment 
by the air-douche was persevered in until the hearing on one 
side was raised to the natural standard, and on the other improve- 
ment would go no further. 

Case II. — Some affection of the Auditory Passages — Opacity of the left 
Membrana Tympani — Clogged state of the Tympanic cavities from accu- 
mulated Mucus — Eustachian Tubes pervious. 

Master C. D., betwixt 12 and 13 years of age, was brought to 
me by his mother, in the beginning of March, 1838, who stated 
her son had just been sent home from school, being no longer 
able to go through his exercises on account of increasing deaf- 
ness. The deafness, I was informed, had been first observed to 
come on after the measles, about four or five years ago. Is sub- 
ject to catarrhal attacks in the nose and throat ; has been under 
treatment without advantage. 

The young gentleman could hear my watch with both ears at 
a distance only of an inch and a half. Thick lips ; the nose 
broad at its root, and the state called epicanthus, i. e., folds of 
skin extending from the sides of the root of the nose over the 
inner canthi ; together with an habitually loaded tongue and 
enlarged tonsils, were points in the constitution of the patient 
worthy of being noted. 

On examining the auditory passages, I found them not stopped 
up, but scales of unhealthy wax adhering to their walls, and 
projecting into their interior, so as to prevent my obtaining a 
view of either membrana tympani. 

Auditory passages directed to be syringed out every second 



CLINICAL OBSERVATIONS. 



267 



night, and a solution of the acetate of lead (gr. iij. to 3j.) to be 
poured in two or three times a day. 

Mrs. C. D. being anxious that her son should not be kept from 
his studies, especially as it was now so near the Easter holidays, 
when he should, of course, be at home for some time, he was 
allowed to return to school with the above prescription. Under 
its use the hearing improved so far that the scholastic exercises 
were gone through without marked impediment, which induced 
the master to write home, saying his pupil's hearing was re- 
stored. 

Thursday, April 12. — Has just returned from school, to re- 
main at home during the Easter, holidays. 

On examining the auditory passages, I found them free ; but 
at one or two places there was a small scab. The membrana 
tympani of the right side was pretty natural — perhaps only a 
little red. The membrana tympani of the left side was quite 
opaque, and presented large dark-coloured varicose vessels 
streaming through its substance. It was still sensible to the 
touch of a probe. 

Saturday, 14th. — The hearing distance is now eight inches 
on the left side, and five inches on the right. 

Introduced a catheter into the Eustachian tube of the right 
side, and blowing simply with the mouth, found it admitted the 
air. The hearing distance was immediately raised to seven or 
eight inches. The Eustachian tube of the left side impervious 
to a stream of air blown from the mouth. 

Monday, 16th. — In consultation with Sir James Clark. Hav- 
ing stated the results of my examinations of the case, and that 
I believed there existed an accumulation of mucus in the tym- 
pana, which would require the employment of the air-douche 
to disperse, it was resolved, before having recourse to that, to 
exhibit some general remedies calculated to improve the state 
of the mucous membranes. The throat and tonsils being red 
and swollen, but not affected with any acute inflammation, were 
ordered to be pencilled daily with a solution of lunar caustic. 

Friday, 20th. — Hearing distance on right side nine inches ; 
on left side eight inches. 

Sunday, 22d. — Throat improving. 

Monday, 23d. — Hearing distance on right side one foot and 
a half; on left side eleven inches and a half. 

On another day in the course of this week the hearing distance 
had, on the left side, risen to one foot one inch and a half; but 
on the right side fallen as low as three inches and a half. 

Saturday, 2Sth. — Hearing distance on both sides eleven inches 
and a half. To leave for school on Monday. 

Saturday, 23d June. — Returned from school for the Mid- 



2g8 CHRONIC DISEASES OF THE EAR. 

summer holidays. Hearing distance of the right ear about six 
or seven inches ; of the left about twelve or thirteen inches. 

Has had since last report, while at school, several attacks of 
ear-ache in the right ear. 

To rub tartar emetic ointment behind this ear. 

Monday, 2d July. — Hearing distance of the right ear about 
one foot ; of the left ear fourteen or fifteen inches. 

Friday, 6th. — Sent in a stream of air, by means of the air- 
press, through a catheter introduced into the right Eustachian 
tube, whereupon the hearing distance was raised to one foot 
eleven inches. Threw in a stream of air on the left side also, 
after which the hearing distance was increased to one foot eight 
inches and a half. 

During these applications of the air-douche, I found that, on 
the left side, the air penetrated less freely, and with more gur- 
gling, than on the right side. 

The good result of the first essay with the air-douche in this 
case confirmed the diagnosis I had ventured to draw from my 
previous observations, especially from the examination made by 
blowing air through the catheter with the mouth simply, and 
emboldened me to pronounce a favourable prognosis, qualified 
only by this — that, considering the extent to which the left ear 
had suffered from inflammation, as indicated by the opaque and 
thickened state of the membrana tympani, it was not likely to 
be so much improved as the right, in which no marked organic 
change could be detected. This prognosis, though verified by 
the event, had like to have been contradicted by the unfavour- 
able turn the case took during the three following days. 

Saturday, 7th. — Had an attack of ear-ache in the right ear 
this morning, in consequence of which the hearing distance has 
fallen to fourteen inches. The left ear, however, has still further 
improved, viz., to two feet and a half. 

Sunday, 8th. — Ordered to day six or eight leeches, to be ap- 
plied around the right ear ; and the tartar emetic ointment, as 
prescribed on the 23d June, to be continued. Sweet oil to be 
dropped into the ear, which is to be syringed with lukewarm 
water at bed-time. 

Monday, 9th. — The leeches have been applied, and the cheek 
is swollen in consequence. No return of ear-ache, but the hear- 
ing distance has fallen on the right side to three inches, and on 
the left side to eight inches, 

Introduced a catheter into the Eustachian tube of the left side 
without causing any pain, and applied the air-douche. The air 
entered with a rushing sound at first, and on increasing the force 
of the stream, with a gurgling sound. After this the hearing 
distance was, on the left side, ten inches. 



CLINICAL OBSERVATIONS. 



269 



Friday, 13th. — No longer any tenderness of the ear. . Hear- 
ing distance on the right side, fourteen inches ; on the left side, 
one foot nine inches. 

Applied the air-douche to the right ear, after which the hear- 
ing distance was raised to two feet. 

Monday, 16th. — Right ear, two feet and a half; left ear, two 
feet. 

Applied the air-douche to the left ear, by which the hearing 
distance was raised to two feet eight inches. 

Tuesday, 17th. — Right ear, two feet eight inches; left ear, 
three feet. 

Applied the air-douche to the right ear, after which the hearing 
distance rose to three feet nine inches and three-quarters. 

Wednesday, 18th. — Right ear, four feet two inches ; left ear, 
two feet ten inches. 

Applied the air-douche to the left ear, without any change in 
the hearing distance immediately resulting. 

Thursday, 19th. — Right ear same as yesterday; left ear, 
three feet three inches. 

Applied the air-douche to the right ear. The stream was 
allowed to be a little more powerful than usual, which caused 
some pain. A rushing sound was first heard, until the force of 
the stream was increased, when a gurgling noise became dis- 
cernible. After the application of the air-douche, the hearing 
distance of the right ear was found risen to six feet. 

Friday, 20th. — Right ear, six feet three inches ; left ear, four 
feet eight inches. 

In consequence of some tenderness of the left external ear, the 
air-douche was not applied to-day. 

Monday, 23d. — Tenderness of the left external ear gone. 

Hearing distance on the right side, seven feet seven inches and 
a half; on the left side, five feet eleven inches. 

Applied the air-douche to the left ear, and immediately found 
the hearing distance only four feet eight inches; but on trying it 
again, in the course of a few minutes it was found to have risen 
to seven feet and a half. 

Tuesday, 24th. — Right ear, seven feet eight inches and three- 
quarters ; left ear, eight feet one inch and a half. 

Applied the air-douche to the right ear. When the air enters 
the tympanum with moderate force, a rushing sound only is 
heard ; but if with greater force, a gurgling noise is perceptible. 
A few minutes after the air-douche, the hearing distance was 
found to be nine feet four inches. On trying it again, after an 
interval of a few minutes, it was found to be almost twelve feet. 

Wednesday, 25th. — Right ear, twelve feet eleven inches ; left 
ear, nine feet one inch. 

A few minutes after the application of the air-douche to the 

34 



270 



CHRONIC DISEASES OF THE EAR. 



left ear, the hearing distance was eleven feet four inches. After 
an interval of five minutes from the first trial, the hearing dis- 
tance was found risen to thirteen feet one inch and a half. 

Thursday, 26th. — Right ear, fourteen feet three inches ; left 
ear, ten feet and a half. 

Applied the air-douche to the right ear. At first there was a 
gurgling, as if there was in the cavity of the tympanum thin 
loosened mucus. A rough rushing sound was afterwards heard, 
as if something vibrated within the tympanum, or as when one 
blows on a bit of gold-beater's skin, stretched between the fin- 
gers. This sound appears to be owing to vibration of the mem- 
brana tympani. 

Hearing distance on the right side was now fifteen feet and a 
half, and in the course of five minutes had risen to sixteen feet 
five inches. 

Friday, 27th. — Right ear, seventeen feet and a quarter ; left 
ear, eleven feet eleven inches. 

After the application of the air-douche to the left ear. the 
hearing distance of it was twelve feet five inches. 

Saturday, 28th. — Right ear, eighteen feet four inches and a 
half; left ear, fourteen feet one inch and a half. - 

Air-douche applied to the right ear. The patient now hears 
the ticking of the watch distinctly, from one corner of the room 
to the other, a distance of about twenty-five feet. 

Monday, 30th. — Hears with the right ear the watch, from 
one corner of the room to the other ; left ear, fifteen feet and a 
quarter. 

After the application of the air-douche to the left ear, the 
hearing distance was found risen to about eighteen feet. 

Tuesday, 31st. — Left membrana tympani, though still opaque, 
does not appear so much thickened as before. It glistens more 
naturally than it did. The handle of the malleus may now be 
seen. The appearance of the right membrana tympani is pretty 
natural. 

Hears the watch with the right ear distinctly, from one corner 
of the room to the other. Hearing distance of the left ear, four- 
teen feet five inches. 

After the air-douche to the left ear, the hearing distance was 
about seventeen feet. 

Thursday, August 2. — Hears the watch distinctly with the 
right ear, from one corner of the room to the other, but did not 
hear it with the left ear at quite such a distance as the day 
before. 

Applied the air-douche to the left ear without much change, 
the hearing distance remaining at only about fifteen feet. 

Friday, 3d. — Right ear continues good ; left ear hears the 
watch at the distance of sixteen feet four inches. 



CLINICAL OBSERVATIONS. 



271 



Saturday, 4th. — Dismissed cured, and is to go back to school 
on Monday. To guard against a relapse, it was directed, in 
addition to the general instructions regarding diet and regimen, 
which were obviously indicated, that in the event of ear-ache 
coming on again, leeches should be freely applied without loss 
of time, the ear fomented with warm water, and warm sweet- 
oil dropped in. 

Saturday, 18th. — Received a letter from Mrs. C. D. to-day, 
in which she says her son is quite as well as when I saw him 
last ; and although he had had a slight cold since, it had not in 
the least affected his hearing. 

Remarks. — In this case, the principal cause of the deaf- 
ness was accumulation of mucus in the tympanic cavities. There 
was no particular obstruction of the Eustachian tubes ; it merely 
appears, that at first the Eustachian tube of the left side was 
impervious to a stream of air blown from the mouth ; and that 
at the first application of the air-douche, the air penetrated less 
freely and with more gurgling than on the right. That the af- 
fection of the auditory passages had some share in the production 
of the deafness, was shown by the circumstance, that, when they 
were restored to a more healthy state, the hearing distance was 
raised a few inches, and the susceptibility to the human voice very 
much improved ; but, unlike what occurred in the preceding 
case, the clogged state of the tympana prevented improvement 
to any considerable extent. The increasing ratio in the progress 
of improvement, under the use of the air-douche, illustrates well 
both the nature of the principal cause and the efficiency of the 
means adopted for its removal. That hearing was not so fully 
restored on the left side as on the right, was owing to the opaque 
and thickened state of the membrana tympani, and possibly to 
a similar state of other parts of the ear not accessible to view. 

As to the origin of the state of the ears. 

The deafness, it is said, was first observed to come on after 
the measles. Both the eye and the ear, it is well known, are 
particularly obnoxious (especially in scrofulous constitutions) to 
what is called the dregs of the measles, as well as of the other 
exanthemata. Ophthalmia tarsi, scrofulous ophthalmia, chronic 
dacryocystitis, &c. — all diseases involving tegumentary structures, 
are very often excited by the measles, &c. The accessory parts 
of the ear being in like manner chiefly composed of the tegu- 
mentary tissue, readily participate in the various affections of 
the skin. In the case before us, I believe we have a counterpart 
of the diseases of the eye, excited by the same cause. The tegu- 
mentary lining of the auditory passages, with the ceruminous 
glands, were affected. Now this resembles, in many respects, 
that disease of the eye called ophthalmia tarsi. In both cases 
the structure affected being a tegumentary tissue in the transition 



272 CHRONIC DISEASES OF THE EAR. 

from skin to mucous membrane ; in the one connected with the 
ceruminous glands, and in the other with the Meibomian follicles- 

But in addition to the affection of the tegument of the auditory 
passages, there was some affection of the mucous membrane 
lining the cavity of the tympanum, giving rise to the accumula- 
tion of mucus ; an affection which might be compared to the 
scrofulo-catarrhal ophthalmia, or to chronic dacryocystitis, dis- 
eases, as above mentioned, often excited by measles, and often 
existing along with ophthalmia tarsi. 

This comparison of the pathology of the case under considera- 
tion with morbid states of the accessory parts of the eye, excited 
by the same cause, indicate the propriety of employing the same 
general means of cure ; but, as was pointed out in my former 
communication, in regard to some parts of the local treatment, 
what is of easy application to the eye requires a complicated 
apparatus for the ear. 

Unfortunately, cases such as the above have a great tendency 
to relapse, either in consequence of the membrane — the seat of 
the disease — not being restored to a healthy action, and thus 
giving rise to a reaccumulation of mucus, or in consequence of 
a new attack of inflammation to which the part will continue 
as liable as at first, or more so. This is not to be surprised at 
when we reflect on the difficulty of completely curing a chronic 
conjunctivitis, a chronic dacryocystitis, or even a chronic inflam- 
mation of the mucous membrane of the nose and throat ; or the 
liability of these diseases, when cured, to fall back from the 
slightest causes. 

Master C. D. came under my care again eight months after 
he was dismissed cured, for a renewal of deafness, brought on 
by repeated attacks of ear-ache while at school. No measures 
having been taken immediately to subdue the inflammation, the 
cautions and advice given when he was dismissed having been 
entirely neglected, the membrane lining the tympanum has, I 
believe, become much changed in texture, so that the character 
of the disease is considerably different from what it was before. 

The further history of the case will be given along with others 
treated with the vapours of acetic ether thrown into the tym- 
panum. 

No. III. — Case III. Chronic Inflammation of the Lining Membrane of the 
Tympanic Cavities, with accumulation of Mucus — No obstruction of the 
Eustachian tubes — Auditory passages natural. 

27th Jan. 1839. — The subject of this case was sent by Mr. 
Quain, of University College, with the following note : — 

" My dear Sir, — Mr. E. F., the bearer of this, has been more 
or less deaf for a considerable time, and, from a short examina- 
tion, I am inclined to think the Eustachian tubes at fault. 



CLINICAL OBSERVATIONS. 



273 



" I shall be much obliged if you will be so good as to examine 
him and give me your opinion. The tendency of my own opi- 
nion is, that the local means — catheterism, &c. - — may be be- 
neficial ; yet, judging from his appearance, the diathesis, so to 
say, it is probable they will not alone be of any great utility. 
* * * I am, &c. 

R. Quain." 

Mr. E. F. is 19 years of age ; had scarlet fever when he was 
six; after that the deafness came on. Is subject to attacks of 
ear-ache. His sister was born quite deaf, but after having scarlet 
fever she acquired hearing ! 

Skin coarse, with the sebaceous follicles of the face much de- 
veloped ; habitually costive. The climate in which he usually 
resides is very moist. 

In September and October, 1836, was treated in Paris, by M. 
Deleau, who applied the air-douche about fourteen times, but 
only with temporary benefit. Took iodine last summer accord- 
ing to the prescription of Dr. Elliotson. During the last autumn, 
hearing improved of itself considerably, but has been diminishing 
since he came to London. It is now — left ear, 3 inches ; right 
ear, 5 inches. 

Left membrana tympani and handle of the malleus appear 
natural ; the right also. The skin of the auditory passages 
slightly red and tender. The secretion of wax natural. 

Applied the air-douche to both ears, as an exploratory means. 
On the left side the air entered freely but with great gurgling ; 
on the right side not so freely, and with less gurgling. 

After the air-douche, the hearing distance of the left ear was 
nine inches, of the right ear seven inches. The hearing was 
further raised on both sides to one foot, by making forced expi- 
rations with the nose and mouth closed. 

Tuesday, 29th Jan. — In consultation with Mr. Quain, and 
Mr. Gasquet of Burton Crescent. Hearing distance to day — 
on the left side, eight inches ; on the right side, one foot. 

After the application of the air-douche, the hearing distance 
on the left side was raised to one foot four inches, on the right 
side to one foot and a quarter. 

To continue the treatment with the air-douche, and endeavour 
to improve the state of the constitution by attention to diet and 
regimen. To resume the use of the iodine. 

Wednesday, 30th. — Left ear, one foot one inch ; right ear, 
one foot and three-quarters. Some pain in the right ear last 
night, and still some tenderness. 

Applied the air douche to the left ear only : the air entered 
freely. 



274 CHRONIC DISEASES OF THE EAR. 

After the air-douche the hearing distance of the left ear was 
one foot and three-quarters ; that of the right ear, although not 
treated, was found increased also — from one foot and three- 
quarters to two feet four inches and a half. 

After some minutes, and after having forced air into the tym- 
panum by attempting to expire with the nose and mouth closed, 
the hearing distance on the left side was raised to three feet, and 
on the right side to three feet and a quarter. 

Thursday, 31st. — Left ear, from two feet to two feet and 
a half; right ear, three feet. After forcing air into the middle 
ear, by attempting to expire forcibly with the nose and mouth 
closed, the hearing distance of the left ear rose to three feet and 
a half, and that of the right ear fell to two feet and a half. 

Applied the air-douche to the right side only. The hearing 
distance was diminished immediately after, but in the course of 
a few minutes it was found risen again to three feet. 

Tuesday, 5th Feb. — Right ear, two feet and a half, at first 
trial, but after forcing air into the Eustachian tube, by attempting 
to expire with the nose and mouth closed, the hearing distance 
was found raised to four feet. 

Left ear, one foot ten inches at first trial ; three feet one inch 
and a half after the forced expiration. Some cold in the head, 
and tenderness about the external auditory passages. No air- 
douche to-day. 

To apply leeches behind the ears. 

Tuesday, 12th. — Leeches have not been applied. Left ear, 
one foot four inches ; right ear, two feet. After a forced expi- 
ration, left ear, two feet five inches ; right ear, three feet three 
inches. 

Friday, 15th. — Ear-ache has shifted from the right to the 
left side. Has had some leeches applied behind the left ear. 

To repeat the leeches. 

Monday, 18th. — Has had ten leeches applied behind the left 
ear. Still some pain and tenderness of the left ear. 

Tuesday, 19th. — No pain, but still some tenderness. Fo- 
mented the ear last night with warm water. 

To rub in tartar emetic ointment behind and below the left 
ear. 

Thursday, 21st. — Left ear, one foot ; right ear, one foot and 
three-quarters. Still some tenderness of the left ear. Pain is 
excited when air is forced into the tympanum by attempting to 
expire with the nose and mouth closed. 

Tuesday, 26th. — Right ear, two feet three inches ; left ear, 
two feet one inch. No recurrence of ear-ache. 

Wednesday, 27th. — Again some pain in the left ear. Hear- 
ing not so good to-day. Nasal catarrh continues. 



CLINICAL OBSERVATIONS. 



275 



Friday, 1st March. — Hearing very dull to day ; no ear-ache. 
Air-douche applied to both sides. The air entered freely, but 
produced great gurgling. No pain during the application of the 
air-douche ; but the Schneiderian membrane is so tumid that a 
very small catheter only can be passed along the nostrils with- 
out causing pain. 

The cold is now going off ; the mucus is therefore increased 
in quantity and becoming thicker, hence the greater degree of 
deafness. 

After the air-douche, the hearing distance on the right side 
was one foot eleven inches, on the left side one foot six inches. 

Saturday, 2d. — Right ear, one foot eleven inches ; left ear, 
one foot nine inches and a half. 

Right ear treated. The hearing duller immediately after the 
application of the air-douche. 

Monday, 4th. — Right ear, one foot nine inches ; left ear, one 
foot two inches and a half. 

Left ear treated. Some obstruction to the free entrance of 
the air at first, but that was readily overcome, and then the air 
entered freely. 

After the air-douche, the hearing distance of both ears was 
about two feet and a half. 

Wednesday, 6th. — Right ear, two feet eleven inches ; left 
ear, two feet five inches. 
Right ear treated. 

Friday, 8th. — Does not hear so well to day, but does not 
complain of ear-ache. 

Monday, 11th. — Right ear, one foot three inches; left ear, 
one foot. 

Applied the air-douche to both sides. After the air-douche, 
the hearing distance of the right ear was found raised to two 
feet and a half; of the left ear, to one foot eight inches. 

Tuesday, 12th. — Right ear, two feet and a half; left ear, two 
feetr 

Left ear treated. During the injection of the air, felt a sudden 
pain in the situation of the mastoid cells. 

Wednesday, 20th. — Right ear, one foot four inches ; left ear, 
only seven inches. 

Air- douche applied to the left ear — great gurgling. 
Thursday, 21st. — Right ear, one foot ; left ear, one foot nine 
inches. 

Air-douche applied to the left ear to-day again, the right nos- 
tril being too tender to allow the catheter to pass. During the 
application of the air-douche felt a sudden pain, as on Tuesday, 
the 12th. 

After the air-douche, the vapour of acetic ether, diffused in 
air, was allowed to flow gently into the tympanum. 



276 CHRONIC DISEASES OF THE EAR. 

After this treatment by the air-douche and ethereal vapours, 
the hearing distance of the left ear was two feet and a half. 

Friday, 22d. — Hears well to day, but has not time to be 
treated. 

Monday, 25th. — Right ear, four feet one inch ; left ear two 
feet seven inches. 

Right nostril still too tender to admit of the introduction of the 
catheter. 

Left ear treated by the air-douche and ethereal vapours. After 
this treatment the hearing distance was three feet four inches. 

Tuesday, 26th. — Right ear, three feet seven inches. Left 
ear, one foot eight inches. v 

Left nostril so tender as not to allow of catheterism to-day. 
The tonsils and uvula red and swollen. The mucous membrane 
of the nose also red and swollen. 

To apply a leech within each nostril, and to take a dose of 
jalap and rhubarb. 

Wednesday, 2d April. — Right ear, one foot nine inches. 
Left ear, two feet. 

Left ear treated. 

Monday, Sth. — Right ear, two feet three inches. Left ear, 
three feet six inches. 

Right ear treated. After the treatment heard the watch at 
the distance of six feet. 

Wednesday, 10th. — Right ear seven feet three inches. Left 
ear, three feet four inches. Left nostril too sensitive to allow 
the passage of the catheter. 

Right ear treated by the air-douche and the ethereal vapours. 

Friday, 12th. — Right ear, seven feet and a half. Left ear, 
one foot and a quarter. 

Left ear treated. A pricking sensation felt in the ear, from the 
ethereal vapours. 

Has heard, yesterday and to-day occasionally, sounds like the 
beating of a hammer. 

Monday, 15th. — Right ear, seven feet six inches. Left ear, 
4 feet ten inches. 

Has not heard the beating since. Right ear treated. 

Friday, 10th of May. — Has been in the country since the last 
report. 

Right ear, 9 feet, 2 inches. Left ear, 7 feet, 5 inches. 

The hearing having improved so much of itself while in the 
country, I thought it advisable not to pursue the local treatment 
any further, but to wait and see what the powers of nature would 
do. 

I have seen this patient twice since, when he complained that 
his hearing was becoming dull again. 

Remarks. — The result of this case has in some degree justi- 



CLINICAL OBSERVATIONS. 



277 



fied me anticipation of Mr. Quain. The scrofulous diathesis, 
with an unhealthy state of the tegumentary system in general, 
evident in this patient, was a great obstacle to permanent im- 
provement. As in Case II., the disease of the ear was called 
into existence by an exanthema. It appeared to be confined to 
the middle ear, the mucous membrane of which was in a state 
of chronic catarrhal inflammation, alternately calming down and 
becoming aggravated. All that the air-douche appeared to do 
when applied by M. Deleau, as well as when I applied it, was 
to effect the dispersion of the accumulated mucus, and so im- 
prove the hearing for a time. The affected membrane, how- 
ever, not being at the same time restored to a healthy action, 
the mucus was always re-accumulating ; hence the constant ten- 
dency to relapse, and the comparatively small progress made by 
the treatment above recorded, until the membrane lining the 
tympanum was directly acted on by the vapours of acetic ether. 
After this, the improvement was more striking than before, and 
probably, if it had been persevered in, decided and permanent 
advantage would have been ultimately gained. 

A point worthy of notice was the improvement in the hearing 
effected by forcible expirations with the nose and mouth closed. 
It has been long known, that by making a forced expiration 
with the nose and mouth closed, deafness is in some cases con- 
siderably relieved. With such facts, Deleau remarks, it is sur- 
prising that blowing air artificially into the tympanum in deaf- 
ness was not thought of sooner. Archibald Cleland spoke of 
blowing air into the tympanum a hundred years ago, but his 
was a mere suggestion, and I do not find that he meant the air 
should be sent in by any other means than by the operator 
blowing with his mouth through a flexible tube (the ureter of a 
large animal) attached to the catheter introduced into the Eus- 
tachian passage.* When the hearing is improved by merely 
forcing the breath through the Eustachian tubes into the tympa- 
nic cavities, it is in general a sign promising farther advantage 
from the air-douche. In recent cases of muculent obstruction of 
the tympanic cavities, without obstruction of the Eustachian 
tubes, very considerable improvement may in this way be ob- 
tained, as in the following : — * 

Case IV. Friday, 26th April, 1839. — Master G. H. aged 

* Wathen's cases by aqueous injections are well known. Busson (an 
absque membranes tympani apertura topica injici in concham possint. Paris, 
1784. Haller, Collect. Diss. Chir. t. 2, p. 286) proposed to effect the dis- 
charge of fluids effused into the cavity of the tympanum by forcing vapours 
into the Eustachian tube. His proceeding was to fill the mouth with the va- 
pours, close the lips and nose, and then make a long forced expiration, by which 
the vapour is driven through the Eustachian tubes into the tympanum. 

35 



278 CHRONIC DISEASES OF THE EAR. 

about 14. Hears the watch at the distance of nine inches on 
either side. The deafness has been occasional in occurrence for 
some time, and varied in degree. Has had sore throat lately, 
but is now better. The tonsils are somewhat enlarged, and the 
uvula long. A rather too copious secretion of wax, which ap- 
pears at the very entrance of the auditory passages, though it 
does not stop them up. 

On making the patient expire forcibly with the nose and mouth 
closed, the hearing distance was raised on the right side to four 
feet nine inches, and on the left side to five feet seven inches. 

If the obstruction be of some standing, such an event does not 
so readily take place, but that more or less improvement may be 
obtained by it is shown in Case III., and Dr. Sims [Memoirs of 
the Medical Society of London) mentions a case in which forc- 
ing the breath into the Eustachian tube, with the nose and 
mouth closed, proved successful after the deafness had continued 
for more than a year. 

The subject of Case III. took iodine, though not with any 
marked advantage. This medicine was first employed in deaf- 
ness by Dr. Manson,of Nottingham, who however gave no par- 
ticular diagnosis for the cases in which it proved useful. But 
as he also succeeded in curing chronic dacryocystitis by the same 
remedy, I am inclined to think that in Dr. M. ? s cases the deafness 
was owing to affection of the mucous membrane of the middle 
ear, especially as I have shown that the membrane lining the 
tympanum and Eustachian tube, and that lining the lacrymal 
sac and nasal duct, strongly resemble each other, both in their 
structure and in their diseases. It is in children, however, and 
at the commencement of the complaint, that iodine has most in- 
fluence in diseases of the ear. 

In the course of Case III. it is several times mentioned that 
the hearing was diminished immediately after the air-douche : 
Dr. Kramer considers this a positive sign of nervous deafness. 
Whether it be so or not, the state of the middle ear in this patient 
was sufficient, in myopinion,toaccountforallhisdeafness,and the 
improvement gained from the application of the ethereal vapours 
bore too strong an analogy to the speedy and marked improve- 
ment, derived from a stimulating application in chronic catarrhal 
ophthalmia, to induce me to look deeper for a part which might 
be supposed to be that at fault, and therefore the one benefited 
by the remedy. 



XERV0US DISEASES OF THE EAR. 279 

CHAPTER III. 

ON THE NERVOUS DISEASES OF THE EAR. 

These affections may be arranged under two heads : first, 
Disordered Function of the Acoustic Nerve ; and, second, 
Disordered Function of the Nerves of common Sensibility 
and Motion, or of the Tympanal Nerves, as they may be 
termed, being contained for the most part in that cavity. 

The first division includes the only diseases of the laby- 
rinth which Dr. Kramer can recognize as such. How 
far this may be correct we have already seen. 

The functional derangements of the auditory nerve, so 
termed, because the disturbed actions do not arise from 
any appreciable organic change in the structure of the 
nerve, may be caused by various circumstances ; for in- 
stance, disease and injury of the brain, affections of the 
middle ear, or of the neighbouring structure, may and 
do excite imperfect action in the nerve, without pro- 
ducing diseased structure which can be recognized by the 
anatomist. But as in these cases the altered function is 
merely a symptom of organic disease in the vicinity, it 
is very properly not treated in itself as an abnormal con- 
dition. The nerve, in some part of its course, and 
perhaps through the whole extent, or more likely at 
one of the extremities, undergoes such an alteration in 
action as to give rise to a serious train of symptoms. It 
is probable that in all cases there exists some change in 
structure, though too minute for detection, either in the 
nerve, or the part of the cerebral mass with which the 
nerveis attached, but when, as so frequently happens, such 
change cannot be demonstrated, it would be unphilosophic 
to consider it as a fact, however much we may be inclined 
to suspect its real existence. That the nerve undergoes 
organicchange from disease has already been shown. 

The functional derangement of the auditory nerve has 
been correctly divided into two states : the Erethitic or Ex- 
cited, and the Torpid. The former may be called the 
acute, and the latter the chronic form ; these two condi- 



280 NERVOUS DISEASES OF THE EAR. 

tions, indeed, frequently stand in relation to each other of 
cause and effect, resembling so far acute and chronic in- 
flammation. 



Section I. 

The Irritable condition of the nerve generally arises 
sympathetically, either with the general health ; and fre- 
quently from an over-plethoric habit; with disease of the 
tympanum especially ; or with some local affection ; thus 
it may sympathise with a disordered brain, stomach, 
bowels, uterus, &c. ; it often occurs from over-use of the 
organ, in the same way as the retina loses its suscepti- 
bility to healthy impressions, and becomes abnormally 
excited from over-action ; it is also a very common atten- 
dant upon fever during the stage of excitement. This 
affection, however, frequently arises without any evident 
cause, although a latent one may still exist. 

The patient is much annoyed by sounds in his head, 
a tinnitus aurium, which the patient compares to various 
noises, such as the ringing of bells, roaring of waves, buz- 
zing of insects; these sounds are at first usually grave 
and afterwards acute, frequently preventing sleep, — he 
is deaf on the affected side, often to a considerable extent. 
One of the most annoying symptoms is a pulsation in the 
ears, synchronous with the heart's action, more or less 
constant, and always much augmented by mental excite- 
ment or bodily fatigue. The Author frequently sees a 
gentleman whose existence is made miserable from this 
cause. These unpleasant sensations shift from side to 
side ; and though they almost always begin in one ear, 
frequently terminate by affecting both. 

At other times the affection commences and proceeds 
more gradually; the hearing being impaired, and the 
above sensations produced, only when listening to minute 
sounds, which circumstance may be forgotten until the 
disorder becomes more severe. These symptoms are in- 
creased by circumstances affecting uncomfortably the 
mind or body, and are lessened by quietude, cheerfulness, 
and improvement of health. It has been particularly 



EXCITED FUNCTIONAL DERANGEMENT. 



231 



noticed by Sir A. Cooper, and confirmed by many others, 
that the meatus externus is dry, the secretion of cerumen 
being lessened, by which the patient's annoyances are 
increased. 

The disease proceeds to such an extent as to incapaci- 
tate the sufferer from attending to his avocations, and it 
may exist for many years, or even during life. In se- 
vere, and long continued cases, otalgia is sometimes ex- 
cited, which extends to the surrounding muscles and 
skin. 

A curious circumstance is connected with this affec- 
tion; the patient can sometimes hear the human voice 
and hold a conversation, when the surrounding noise is 
very great, as in a carriage, or walking along a noisy 
street, whereas without this loud accompanying noise he 
would be deaf to the slighter sound. Various reasons 
have been assigned to account for this phenomenon, such 
as the relaxation of the membrane, or the tenser tym- 
pani ; it most probably, however, is owing to the nerve 
roused into action by the loud sounds, being then enabled 
to appreciate those more minute ; if, indeed, as appears 
probable, it is not altogether ideal and depending upon 
the circumstance of the healthy individual raising his 
voice to overcome the noise which confuses his audition, 
and which only being partially heard by the deaf per- 
son, he distinctly recognises the elevated and clear speech. 
The different shades of hearing, are only symptoms of 
this affection, as the Hypercusis, Paracusis, &c. ; thus 
again it bears among many other particulars a resem- 
blance to amaurosis. The disorder frequently terminates 
in incurable torpor ; and therefore requires a guarded 
prognosis. 

The Treatment consists in removing if possible any 
general or local disease which may cause or keep up the 
affection. When attended with general excitement that 
must be combated ; but if, as the Author's experience 
leads him to believe is more usually the case, it is conse- 
quent upon general debility, or nervous excitability, it 
will be more readily relieved by such remedies as tend 
to their improvement ; such as quinine, and other tonics 
which may be considered most applicable to the indivi- 



282 



NERVOUS DISEASES OF THE EAR. 



dual case, together with mild opiates, carefully regulated 
diet, change of air and scene, warm sea-bathing, &c. 
As this affection so nearly in its character resembles 
amaurosis, it is a question if the effects of mercury, which 
in the latter instance are often found to be of such marked 
benefit, might not sometimes be attended with advantage. 
In some cases the introduction of setherous vapour into 
the tympanum, in the manner presently to be described, 
has been attended with benefit, in conjunction with gene- 
ral treatment. Such applications must be adopted only 
in long continued affections, when they have somewhat 
assumed a chronic form ; as in the earlier stages the stimu- 
lant may be injurious. Counter-irritants in the vicinity 
of the ear, and especially blisters behind the auricle are 
found to be important assistants in removing this dis- 
tressing malady. A mild stimulating application, as the 
citrine ointment diluted in the manner already noticed, 
the weak solutions of zinc, of nitrate of silver, of bichlo- 
ride of mercury, may be applied with advantage to 
the meatus, with the hope of promoting the ceruminous 
secretion. 



Section II. 

The Torpid Functional Derangement of the auditory 
nerve is generally the disease of old age, and is the usual, 
but not the only cause of deafness at that period ; for it 
is also probable that the other structures of the ear may 
undergo a change consequent upon long continued use, 
and lessened energy of nutrition. 

This form of functional disorder arises in persons of 
all ages, and is probably sometimes the cause of congeni- 
tal deafness. It often follows the over-excitement of the 
function ; and it is most likely this circumstance, which 
gives rise to the opinion that the ear-drum is broken in 
consequence of the roar of a cannonade, or the breaking 
of stones, or any loud noise, either suddenly applied, or 
long continued. 

When it occurs in old age, the affection comes on so 
very gradually, as to exist often many years before the 



TORPID FUNCTIONAL DERANGEMENT. 



283 



hearing is entirely lost ; whereas in younger persons it 
is generally preceded by an erethitic state of the nerve. 
Concussion of the brain arising from a blow upon the 
head, may also be followed by deafness, from this torpid 
state, more or less complete, and more or less permanent 
It likewise is a frequent attendant upon typhus fever 
after the stage of excitement has passed away, and may 
be then considered a favourable symptom as indicating 
a diminished energy of the general nervous system from 
which the patient usually recovers; not unfrequently, 
however, this hardness of hearing continues after the 
subsidence of the fever. 

This state of the nerve is ascertained to be the cause 
of the accompanying deafness, by the absence of disease 
in the external and middle ears, which require, therefore, 
to be carefully investigated both by the meatus and the 
Eustachian tube, — by the want of perception of sounds 
when the bones of the cranium are thrown into vibra- 
tion, by the watch placed upon them, or between the 
teeth. This torpid condition is generally accompanied 
by some tinnitus aurium, even when it is not preceded 
by the erethitic state. In making his diagnosis the Sur- 
geon must be careful to distinguish between the sense 
of feeling and that of hearing, for the reasons stated in a 
former part of this Essay. 

The prognosis of this affection is usually unfavourable ; 
yet, Dr. Kramer in particular has related some cases of 
successful treatment, and if future experience should con- 
firm his results, his practice must be esteemed as a great 
improvement in aural Surgery. 

The general health of the individual demands the chief 
attention, and if the disease arise from sympathy, the 
original malady must be first improved before we can 
hope for much success from our remedies. The various 
nervous excitants have enjoyed their temporary fame, as 
galvanism, electricity, &c, but have failed to maintain 
their empirical reputation. Itard first introduced through 
the catheter into the tympanum setherous vapour, gener- 
ated by dropping the fluid on hot iron ; and Dr. Kramer 
has, in the same manner, passed the acetous aether, 
vaporised by the heat of the room, into that cavity, 



284 NERVOUS DISEASES OF THE EAR. 

which being milder than the vapour, is not productive 
of any ill consequences, and in his opinion is more 
effectual. 

For the purpose of introducing the vapour, Kramer 
uses a glass jar, to the mouth of which is accurately 
adapted a cork, through which are passed two metal tubes, 
one being furnished with a funnel and stop-cock, for in- 
troducing the fluid, the other with an elastic tube and 
stop-cock ; the jar being half filled with warm water, a 
small quantity of the acetous aether is introduced through 
the funnel, which is immediately closed by the stop-cock ; 
the elastic tube being then fitted to the catheter, previ- 
ously introduced into the Eustachian tube, and then 
opened, the sether vaporised, rushes through the tube 
into the tympanum, sometimes as the Writer has expe- 
rienced, with an audible sound, at others producing but 
little effect. The Author continually uses a wide-mouthed 
bottle, through the cork of which a metal pipe is passed 
in an air-tight manner, which pipe is furnished with an 
elastic tube and stop-cock. The bottle being half .filled 
with warm water, about half a drachm of acetous sether 
is poured into it, and the mouth is immediately closed; 
the little apparatus being very portable, the elastic tube, 
with its stop-cock, is readily attached to the catheter, 
already passed into the Eustachian tube, and the vapour 
is then allowed to flow into the tympanum. As it fre- 
quently happens that the vapour does not pass over by 
these means, probably in consequence of the sether com- 
bining with the water, the Writer often places the bottle 
containing about a drachm of the fluid, in a jug of warm 
water, when in a few seconds the sether is rapidly va- 
porised. He has not met with the inconvenience of 
over-stimulus arising from this plan, to which Dr. Kra- 
mer has alluded. This vapour may be applied two or 
three times at a sitting, which may be repeated daily, or 
every two or three days, according to the effect produced. 
When this stimulant does not seem to be sufficiently ac- 
tive, a very diluted mixture of the acetous sether in water, 
about a drachm to half a pint, may be injected into the 
cavity of the tympanum with frequent benefit. This 
proceeding, however, must be conducted with great cau- 



TORPID FUNCTIONAL DERANGEMENT. 



285 



tion, as the Writer has seen it produce considerable pain, 
and it may excite inflammatory action. The patient's 
deafness is generally increased for a short time, varying 
from a quarter of an hour to a day or more, after the in- 
jection of the gas, and more particularly of the fluid, in 
consequence of the distension of the tympanum interfer- 
ing with the vibration of its membrane. The following 
case exemplifies the good effects occasionally derived from 
this plan of treatment, although justice requires it to be 
stated, that the Author's experience does not warrant him 
in being so sanguine of the general result, as Kramer's 
asserted success would justify ; yet it must be admitted, 
that if only one case out of many which have been deemed 
incurable is restored to hearing, this plan, introduced by 
our Continental neighbours, must be esteemed as a most 
valuable boon to humanity. 

The Rev. W. I. H. states, that " at the age of sixteen 
my sense of hearing was severely injured by a succession 
of violent inflammatory attacks in my ears. About 
thirty-four years have elapsed since that period, and, dur- 
ing all that time, I have been almost entirely deprived 
of the use of my right ear, and have had but an imper- 
fect use of my left. On various occasions, when labour- 
ing under bodily indisposition, I have been afflicted with 
almost total deafness, which has sometimes continued 
long after the indisposition itself had ceased. In the 
course of last winter I was afflicted by a severe and ob- 
stinate attack of quinsy, which, as usual, very much 
affected my hearing. The deafness occasioned by its 
continuing some months after my recovery from this 
attack, I was strongly urged by my kind medical attend- 
ant to submit my case to the inspection of Mr. Pilcher, 
which advice I followed, and soon began to experience 
surprising benefit, particularly in my right ear, which, 
for the greater part of my life, had been almost entirely 
useless. During the few weeks I have been under treat- 
ment, a gradual improvement has been effected, to which 
I am indebted for the perfect recovery of my hearing, 
and a consequent augmentation of the happiness of 
life." 

36 



286 



NERVOUS DISEASES OF THE EAR. 



The treatment pursued in this case was the applica- 
tion of the vapour of acetous aether two and sometimes 
three times a week, the patient's avocations not permitting 
the more frequent use of the remedy ; when the vapour 
did not produce a sensible effect, the much diluted mix- 
ture of aether and water was injected. The right ear 
only has been sufficiently operated upon to produce any 
influence, as, in consequence of a diseased condition of 
the mucous membrane of the left nostril, it is at present 
difficult and somewhat painful to pass the catheter. The 
lining membrane of the external ears of this gentleman 
is dry and scaly ; the Eustachian tubes are large and 
pervious, and the symptoms denote a torpid condition of 
the acoustic nerve, attended with occasional tinnitus 
aurium. 

Cotton, soaked in some gentle stimulant, has been ap- 
plied to the auditory canal, and it is supposed with occa- 
sional benefit in exciting the follicles to action. 

It must never be forgotten that the use of the nerve 
being long neglected, it runs into a state of torpor, from 
which it will be difficult to restore it ; thus, a gentleman 
deaf from an injured membrane, neglected to use that 
ear until he believed it had lost all sensation ; but, be- 
coming deaf on the other side, he found he could hear 
slightly on that originally affected, and by great perse- 
verance, at length heard tolerably well. Hence also this 
non-use of the nerve may become a cause of deaf-dumb- 
ness, the child being hard of hearing from some cause, 
congenital or acquired, the lessened faculty is altogether 
neglected. 



Section III. 

The Functional Derangementof the Tympanic Nerves, 
constitutes the true Otalgia, or Ear-ache. Kramer does 
not allude to this affection : but every one must have 
noticed, and most persons have felt, that the ear is liable 
to be affected with neuralgia, in a manner resembling 
such attacks in other organs of high sensibility ; indeed, 
this structure seems more frequently than others to be 



OTALGIA. 



287 



thus influenced ; and when we call to recollection the 
tympanic plexus of nerves and its distribution, the chorda 
tyrnpani crossing the cavity with its connexions, and the 
close vicinity of the portio dura, our astonishment would 
be rather excited by the absence than the occasional pre- 
sence of such a painful affection. The common causes 
of neuralgia operate here as elsewhere ; the most frequent 
being sympathy with other affections ; and the application 
of cold. Thus, one of the most dreadful concomitants of 
a diseased tooth is the severe pain shooting through the 
ear. No Surgeon can have applied a ligature around 
an enlarged tonsil, without his patient immediately afford- 
ing signs of suffering from otalgia, which is generally 
renewed upon every motion of the gland ; this affection 
is also a common attendant upon Cynanche Tonsillaris, 
independently of the pain excited by the extension of the 
inflammation along the Eustachian tube. A few years 
ago the Author was induced to suspect the existence of 
an enlarged tonsil, from the circumstance of neuralgia of 
that side of the head and ear : an examination confirmed 
his suspicions, and the painful symptoms subsiding upon 
the removal of the gland, the correctness of the diagnosis 
was made apparent. Any disease in the neighbourhood, 
whether in the bones, or in the brain or face, may be the 
cause of the painful ear. Otalgia appears to be especially 
liable to be suddenly excited by the application of a gust 
of cold air to the tympanic membrane, and hence arises 
the common dread of unduly exposing the ears ; that a 
sharp pain exists, indicating an inflammatory state of the 
tympanum, which is often unfortunately too lightly con- 
sidered, has already been seen ; but every observer must 
have noticed, that this symptom of acute pain in the ear, 
often amounting to agony, with increased sensibility of 
its faculty, occurs so immediately upon the application of 
its cause, as to render it impossible to be produced by 
vascular reaction ; and again, it sometimes as rapidly 
subsides, either consequent upon the use of anodynes, or 
without their assistance ; it is, however, frequently a pre- 
cursor of serious mischief. Neuralgia of the tympanum 
or its membrane, is sometimes excited by direct injury, 
as sounding the membrane, to ascertain its state of 



288 NERVOUS DISEASES OF THE EAR. 

health ; the too forcible propulsion of water against it in 
syringing; the introduction of foreign bodies, and the 
attempts at their removal. 

As in all neuralgic affections, the pain varies from a 
slight uneasiness to complete agony, producing delirium, 
the extent depending upon the general and local predis- 
positions, and the cause ; usually there is a continued 
aching pain, with occasional sudden lancinating shoots 
through the ear and the neighbouring parts, particularly 
taking the course of the lower jaw and upper part of the 
neck ; this increased pain generally arises from a renewed 
cause, as mental emotion, or sound of cold air striking 
the membrane, or sudden movement of the head; but 
it frequently occurs without any evident excitement. 
Otalgia is distinguished by the pain, and increased sensi- 
bility, which frequently produces tinnitus aurium of vari- 
ous degrees and shades, and particularly by the absence 
of the symptoms of other diseases. The diagnosis, it must 
be confessed, is sometimes difficult, inasmuch as the pain- 
ful state of the organ often precludes an accurate investi- 
gation, and the affection itself may be merely a symptom 
of other disease. The frequent recurrence of neuralgic 
affection may in time produce organic lesion, either in the 
nerves affected, or their neighbourhood. 

The Treatment must be that which experience has 
shown to be most efficacious, when the disorder is seated 
in other nerves ; namely, removing the exciting cause, if 
one should exist, improving the general health, and exhi- 
biting tonics with opiates. When however the pain is 
severe, more active remedies are required than these gene- 
ral allusions seem to warrant ; thus, full opiates should 
be administered by the mouth ; and the introduction of 
opium into the meatus will generally be attended with 
marked relief; and with this view cotton or wool soaked 
in laudanum and water warmed, a soft suppository of 
opium and gum or soap, or oil and laudanum, may be 
passed into the canal ; narcotic poultices and fomenta- 
tions are valuable adjuncts applied to the external ear and 
side of the head. Purgatives are generally indispensable, 
both to remove any abdominal irritation, which is a fre- 
quent cause of this nervous disorder, and as a prophy- 



OTALGIA. 



289 



lactic means to prevent that inflammation which, it is to 
be dreaded, may succeed ; and with this latter view, de- 
pletion, by means of leeches applied to the vicinity of the 
ear, will often be advantageous. 

Possibly a torpid condition of the tympanic nerves may 
exist, either as a consequence of over-excitement, of injury, 
of old age, or of general disorder ; this state may affect 
the whole nervous system of this structure, or be confined 
to a portion only, as to the excito-motory, the sensiferous, 
or the volition fibrils. If such a condition exist, a para- 
lysis of the muscles of the tympanum must be a conse- 
quence, and possibly also the vibratibility of the membrane 
would be diminished with its sensibility. If this suppo- 
sition be correct, it would seem to be capable of explain- 
ing phenomena which are now inexplicable ; as some of 
those of partial hearing, related by Dr. Wollaston ; and 
the result occasionally produced by direct or indirect in- 
jury ; thus, for example : — 

A gentleman, in consequence of a fall from his horse 
about four years ago, received a violent blow T , which pro- 
duced concussion of the brain, and general ecchymosis on 
that side of the head ; which symptoms having continued 
for a few days, gradually subsided, without evidences of 
inflammation, or lesion of any kind, but he has ever since 
continued perfectly deaf on that ear. Upon examination 
the Author can discover no cause for the loss of function ; 
the auditory meatus and membrana tympani possess 
normal appearances ; the Eustachian tube is pervious 
and otherwise healthy ; readily admitting the injection of 
air and of water into the tympanum, which strike audibly 
against the membrane : the ticking of the watch is dis- 
tinctly heard when placed in contact with the head, face, 
teeth, or with the ear ; but when held close to the auricle 
without being allowed to touch it, the sound is quite 
inaudible. As the labyrinth performs its function, it is 
a fair presumption that the disorder is confined to the 
tympanum. — May not a torpid condition of the tym- 
panic nerves exist ; or, is it possible that a displacement 
of the ossicula may be occasioned by the injury received ? 



290 CONCLUSION. 



CONCLUSION. 

From the foregoing pages it will be learned, that the 
variation in the extent of Deafness is almost infinite ; 
— from the slightest possible, hardly perceptible, defi- 
ciency in function, to its complete loss, in which the 
loudest sound excites no effect, except through the me- 
dium of vibration. This variation in function is in part 
only regulated by the amount of disease of the Ear ; the 
Author daily witnesses cases in which the extent of Deaf- 
ness, and disorganization of structure, by no means cor- 
respond ; the membrane and four ossicles of the tympa- 
num have been lost by disease, and yet the sense of hear- 
ing was so little impaired, as not to be recognised by 
ordinary observers. On the other hand, a collection of 
mucus in the cavity of the tympanum, the effect of mere 
catarrhal inflammation, the organ being otherwise quite 
healthy, has produced deafness so complete, as to occa- 
sion a consequent dumbness. 

These facts in many instances may be accounted for 
by the circumstance of the various undulations being 
transmitted directly across the diseased tympanum to the 
membrane of the fenestra ovalis — or to the stapes or in- 
cus as the case may be — in extensive disease of the mid- 
dle Ear, exciting to action the healthy labyrinth ; whereas 
an interruption to the vibration of the tympanic mem- 
brane, or to the oscillations of the bones, will prevent the 
influence of sound upon the internal Ear ; hence the 
varying accumulations of mucus or muco-pus,in diseases 
either slight or extensive of the tympanum, produce great 
and sometimes sudden variations in the power of hearing. 
The frequent non-correspondence in the loss of function 
of hearing with the apparent disease, is often attributable 
to the difference in the impressibility of the auditory 
nerve ; the augmented capability to receive impressions 
slightly communicated, is remarkable in the labyrinth 
when the tympanum has been early destroyed ; the Sur- 
geon has often to observe a tympanum lost as regards its 
function with but little imperfection in hearing. A medi- 



CONCLUSION. 



291 



cal practitioner, who applied to the Author in conse- 
quence of extreme deafness in one Ear from diseased 
nerve, was naturally astonished when informed, that his 
supposed healthy Ear, with which he heard correctly, 
had the membrane and bones of its tympanum removed 
by disease, and that the membrane of the oval fenestra 
was exposed. 

The variations in the capability of hearing different 
sounds are curious, and perhaps at present unaccounta- 
ble. Thus, a gentleman, with whom the Writer had been 
in occasional communication, without detecting his defi- 
ciency in hearing, was incapable of hearing the watch 
when applied to his Ear, though he rarely lost a word 
in conversation carried on in the ordinary tone. On the 
contrary, another, deaf from diseased brain, implicating 
the auditory nerve, is incapable of hearing the voice, even 
when raised to a considerable pitch, yet can distinguish 
the sound of the watch at some little distance. Again, 
an amateur performer on the flute hears the flat notes as 
naturals, and thus the tune which is harmony to others 
is discord to him, and the reverse. These peculiarities, 
probably, in most instances, depend upon some condition 
partially affecting the acoustic nerve in its expansion ; 
but they also lead to the supposition that different parts 
of the auditory apparatus are more readily influenced by 
peculiar sounds, and seem to confirm the observations 
previously made when discussing the physiology of the 
membrana tympani. 

It is probable that the deafness in the sourd-muet is 
rarely complete, the malformation of the organ being only 
to a degree ; and it is certain that in many cases the par- 
tial audition may be much augmented by assiduous and 
well-directed exercise. Experience, however, justifies 
the belief that from acquired disease the sense is occa- 
sionally totally lost, which most frequently occurs in in- 
stances of paralysed or diseased nerve, the affection usually 
being concomitant with that of the brain, and the latter 
recovering, leaves the Dyseccea as the prominent symp- 
tom or result. 

The causes of the various degrees of deafness are ar- 
ranged under the two heads of congenital and acquired. 



292 CONCLUSION. 

The congenital causes of deprivation of this important 
function, or the malformations of the Ear, we have seen 
to be most frequently recognised in the labyrinth, in which 
either the semicircular canals, or the cochlea, or both 
these structures, have been only partially developed. 
The situation of the membrane of the fenestra rotunda 
has been found occupied by bone. The membranous laby- 
rinth has been deficient ; and the liquor labyrinthi has 
presented abnormal constituents or quantity. The audi- 
tory nerve, also, in its expansion or its tract, has been im- 
perfectly formed. 

The malformation less frequently exists in the tympa- 
num, arid when there it is usually accompanied by a defi- 
cient formation of the labyrinth. 

The abnormal conditions of the middle Ear, so gener- 
ally detected in the sourd-muet, are often, if not usually, 
the effect of struma, and in most instances supervene 
upon the original deficiency of structure in the labyrinth ; 
a circumstance which corresponds to the well-ascertained 
fact, that deaf-dumbness is almost invariably confined to 
individuals of a scrofulous diathesis. As an exception to 
the above observation, it has been noticed that the ossi- 
cula are malformed without abnormal arrangement in 
other parts of the organ, sometimes to an extent to cause 
deafness, though at others only to an immaterial degree. 
It is improbable, from its mode of formation, that the Eus- 
tachian tube is imperfectly developed, independently of 
malformation of the tympanum, or of the fauces ; its 
malarrangement is co-existing with more extensive imper- 
fection. An occasional cause of cognate cophosis exists 
in the inspissation of mucus, or muciform matter, in the 
tympanic cavity, or in the Eustachian tube, or occupying 
both canal and cavity. The exact condition of the middle 
Ear should therefore always be ascertained, asif this cause 
of the defect alone exists, it may be removed ; both the 
diagnosis and removal being effected through the medium 
of catheterism of the Eustachian tube. 

Malformations in the external auditory canal are not 
common, though occasionally they occur; the most fre- 
quent is unnatural diminution in capacity, which, if not 
extreme, will produce but little inconvenience, but it may 



conclusion. 293 

exist even to obliteration of the tube. When such de- 
ficient calibre is confined to the cartilaginous and the 
fibrous textures, it may often be remedied by the use of 
tubes and tents ; but when the malformation is seated in 
the bony structure, the hope of relief must be very faint. 
In the same manner, ossification of the membrana tym- 
pani hardly admits of remedy. As the mucous membrane 
of the Eustachian tube and tympanum, so its counterpart, 
the dermoid canal of the outer Ear, may be occupied by 
inspissated sebaceous, or ceraceous matter, the ordinary 
deposit upon the surface of the newly-born infant, which 
is easily removed soon after birth. 

Maldevelopment of the auricle alone cannot occasion 
interference with hearing, and therefore need hardly be 
alluded to in this general summary. 

Dissections of the Ear the most particular often fail in evi- 
dencing the abnormal cause of congenital deafness, which 
is most probably then concealed in the nervous apparatus 
of the organ, either of the labyrinth or of the tympanum : 
vitiations in these structures, too minute for observation, 
may entirely annul the function. 

It appears that every part of the nervous system, and 
in a marked manner each nerve of special sense, requires 
the application of its own peculiar exciting agent, gradu- 
ally and frequently repeated, to stimulate it, as it were, 
to perform its appropriate function ; hence the truly ani- 
mal senses are not in operation till some time after the 
birth of the infant. This circumstance probably depends 
upon the sense itself, or that part of the brain with which 
it is connected, being perfected only after birth. The 
period required for this capability of action varies in 
individuals, from a few days to several months, and 
sometimes never arrives : hence one cause, and the Au- 
thor imagines, the most frequent and irremediable, of 
deaf-dumbness. 

The vast improvements in the tuition of the sourd-muet 
having introduced speech into his acquirements, the 
slightest amount of hearing becomes an object of great 
importance; hence, whatever may be the cause of the 
defect, exercise of the organ should be diligently perse- 
vered in, to augment, or at least to retain, what little func- 
tion may exist. 

37 



294 CONCLUSION. 

The acquired causes of deafness occur in each divi- 
sion of the Ear, and not infrequent! y in two, or in all three 
at the same time. Though the attention of the Surgeon 
is generally directed, and oftentimes exclusively, to the 
External Ear, it has been shown that the disease causing 
the imperfection is more frequently seated in the tympa- 
num or the labyrinth. 

The tympanum is by far the most common seat of dis- 
ease; either in the form of catarrh, acute or chronic, 
producing temporary or more permanent accumulations 
of mucus ; or of more serious inflammation terminating 
in suppuration, implicating and ulcerating the membrane, 
sometimes with the loss of the ossicles, and the formation 
of fungi protruding through the aperture into the meatus. 
It is fortunate that in all these apparently untoward cases, 
much relief may be afforded ; and in the very common 
affection, strumous thickening of the mucous membrane, 
producing accumulation, a cure may be fairly expected. 
The Eustachian tube participates in the diseases of the 
tympanic cavity, except probably in the fungi or vegeta- 
tions proceeding from its mucous membrane, which are 
rare in the tube, though so common in the cavity. Stric- 
ture of the Eustachian tube, so frequently alluded to as 
a cause of deafness, is an uncommon occurrence. Affec- 
tions of the labyrinth are the next in frequence, as the 
acquired causes of cophosis ; of these, the erethitic or 
excited state of the auditory nerve, generally occurs in 
young and middle-aged persons ; and unfortunately is 
more frequently than otherwise uninfluenced by surgical 
appliances, a minority of cases only yielding to remedies. 
The torpid condition of the acoustic nerve, although not 
confined to old age, is almost peculiar to that period of 
life, and is even more beyond the reach of art than the 
erethitic affection. 

The diseases of the labyrinth coincident with, or conse- 
quent upon affections of the brain, not unfrequently 
continue after the original malady has subsided. The 
Author has witnessed several such cases, in w 7 hich the 
loss of function was more complete than from any other 
cause, not excepting even malformation. From the ex- 
perience of one instance in a child, — in whom cophosis^ 
consequent upon disease of the brain excited by den- 



conclusion. 295 

tition, was so perfect, that of necessity dumbness existed 
during five or six years — yielding to the influence of mer- 
cury, whereby hearing, and consequently speech were re- 
stored; and of others in which some decided improve- 
ment occurred, the Writer indulges the hope, that even 
these deplorable cases may occasionally admit of relief. 

The outer Ear is less frequently diseased sufficiently 
to cause serious deafness than is usually imagined, and 
hence the frequent inutility, and often injuriousness, of 
acoustic applications and nostrums, which are almost 
uniformly applied to the outer canal. The unhealthy condi- 
tion of this auditory tube, so frequently accompanying a 
similar state of the tympanum, the real cause of the co- 
phosis, is very likely to mislead the casual observer ; and 
it is not uncommon to hear the dryness of the meatus — 
symptomatic of diminished energy of the auditory nerve 
— asserted as the origin of the lessened function. Though 
it is probable that every unhealthy state of this structure 
will interfere with hearing, yet it is almost certain that 
nothing short of mechanical interruption to the trans- 
mission of sound, can produce any material effect; hence 
may be enumerated the tumefaction of the lining mem- 
brane ; polypus, fungus, or vegetations of the canal ; 
inspissated wax, and foreign bodies of all kinds. It is 
evident that the effect of extraneous materials and of in- 
sects, will be in proportion to their quantity, and their 
proximity or attachment to the membrane of the tympa- 
num. The fungi so constantly seen at the bottom of the 
auditory canal are, with but few exceptions, products of 
the diseased mucous membrane of the tympanum pro- 
jecting through an aperture in the membrane, and in a 
large majority of cases the effect of scarlet fever. It is 
gratifying to the Surgeon, that all these cases are im- 
provable by his art, and frequently curable. 

The allusion in this Summary to the extent of surgical 
aid in acquired causes of deafness, though brief, is suffi- 
cient to point to the fact, that in the present state of 
knowledge, it is to a distressing degree unavailable, and 
that to a certain extent it will ever remain so ; yet the 
daily advance of science justifies the hope, that more 
may be achieved in this department also for suffering 
humanity. 



296 CONCLUSION. 

Mechanical contrivances have been devised, from time 
immemorial, to obviate the effects of deafness by aug- 
menting the quantity of sonorous waves transmitted to 
the Ear. The empiricism so often accompanying the 
laudations of acoustic apparatuses, attributing to them 
far other than mere mechanical effects, is much to be de- 
plored. As all other remedies whose effects are striking 
and beneficial, so Ear cornets and trumpets are exceed- 
ingly likely to be abused, by being adopted too early and 
used too constantly. The patient should be impressed 
with the fact, that the instrument is useful only by in- 
creasing the undulations conveyed to the organ, and he 
hears consequently better, in the same manner as he 
w r ould a voice loud to the same degree ; and that in pro- 
portion as the sound is augmented, and constantly ap- 
plied, the nerve, for the faulty condition of which the 
instrument is generally required, will become accustomed 
to the greater excitement, its torpidity or erethism will 
increase, and the deafness become worse : the instru- 
ment should therefore be had constant recourse to only 
when every sound is lost without it ; and when hearing 
exists even to a very limited degree, this valuable, yet 
often dangerous aid, should be used only when the sound 
is very low or at a distance, or it is important to catch 
it distinctly. 

The most useful are the common cornets, and they 
should be large and long, shaped upon the principles de- 
scribed in the chapter on the Physiology of Hearing, when 
alluding to the speaking trumpet, though reversed, in 
order to condense most effectually the waves of sound. 
Certain materials seem to add to the effect by their 
greater vibratibility, and hence the bell, or better still, 
the gongj metal is extolled. A simple reflector behind 
the Ear, even so imperfect a medium as the hand, has 
very considerable effect. These instruments are manu- 
factured of very various shapes and sizes, sometimes 
without much reason, but generally for the important 
one of convenience to the wearer, with the least possible 
desight. For these purposes they are often furnished 
with springs for securing them, which is a source of great 
accommodation to those who wear them habitually. 



INDEX. 



Acetic ether, injected into the tym- 
panum for nervous deafness, 283 
Acoustic or auditory nerve, 69 

morbid states of, 133, 279 
disordered function of, 279 

divisions of, 279 
irritable condition of, 280 
torpid state of, 282 
prognosis of, unfavour- 
able, 283 
treatment of, 283 
Air-douche, use of the, in diseases of 

the ear, 179, 260 
Alveus utriculosus, 67 
Antitragicus, 43 
Aquseductus cochleae, 65 
vestibuli, 65 
Fallopii, 66 
Aqualabyrinthi, 67 
Atmosphere, a conductor of sound, 78 
Auricle of the ear, 41 

when first visible, 112 
malformations of the, 113 
acute inflammation of the, 

141 
chronic inflammation of the, 
190 
Axis of the cochlea, 63 

Brain, tympanal inflammation ex- 
tending to, 163, 236 
concussion of, causing deaf- 
ness, 289 

Catacoustics, 84 

Catheterism of Eustachian tube, 254, 

257 
Ceruminoussecretion,excessive,208, 
263 
treatment of, 211 
caution against empiri- 
cal syringing for, 213 



Ceruminous secretion,accidents from, 

260 
Cochlea, described, 23, 62 

when formed, 125 
Cophosis, congenital, 133 
Cotunnus, aqueducts of, 65 

morbid enlargement of, 
131 

Deaf and dumb, organs of hearing 
in, 133, 292 
never taught to speak, 
136 
Deafness, various degrees of, 134, 
290 
congenital, not hereditary, 

137 
nervous, 187 

erethitic, and torpid, 187 
congenital, 292 
acquired, 294 
cornets and ear-trumpets 
for, 86, 296 
Deaf-dumbness, more frequent in 

males than in females, 136 
Diacoustics, 84 
Diagnosis of diseases of the ear, 179, 

260 
Dysecoea, operation for, 121 

Ear, its relative utility, 15-16 
several parts of, 18 
simplest form of, 20 
human, anatomy of, 41 
external, 41 

parts composing the, 41, 
48 
muscles of, 43-45 

proper, 60 
nerves of the, 68 
arteries of the, 73 
abnormal conditions of the, 111 
malformations of the, 111 



298 



INDEX. 



Ear, diseases of the, 138 

chronic diseases of the, 188 

inflammation of, 189 
nervous diseases of the, 279 
middle, mucous engorgement 
of the, 177 
inflammation of the, 157, 225 
lesions of the, 247 
Ear-trumpet, 86, 296 
Ear-ache, 139, 254 
Eustachian tube, 31, 53 

function of, 106 
congenital obliteration 

of, 121 
chronic inflammation 

of, 249 
structure of, 249 
inflammation and 
thickening of, 253 
constitutional treat- 
ment of, 253 
catheterism of the, 254 
External auditory canal, inflamma- 
tion of, 143 
symptoms of, 144 
treatment of, 149 
division of diseases of, 

131 
chronic inflammation 
of, 191 
See Meatus Auditorius Externus. 

Facial nerve, 70 
Fenestra ovalis, 29, 52 

rotunda, 29, 52 

closure of, 130 
Fenestra, vibrations in, 107 

when formed, 126 
Fungus or fungoid excrescence, 200, 

204 
removal of, 206 

Glandulse ceruminosse, 47 

follicular abscess of, 

148 
inordinate secretion of, 
208, 263 

Hearing, definition of, 15 

its relative importance, 15, 

16 
apparatus for, 18 
fundamental organ of, 21 
physiology of, 75 
various limits to, 110 

Helicus major, 43 
minor, 43 



Incus, 55 

Inflammation of the ear, see Otitis 

Labyrinth, parts composing the, 23 
60 
osseous, 61 
membranous, 61, 67 
alterations of, 131 
time of its formation, 124 
abnormal deficiencies in, 

128 
entire absence of, 132 
acute inflammation of, 
185 
Lamina spinalis, 63 
Lobus, 44 

Mastoid cells, 53 

use of, 107 
Malleus, 55 

Membrana tympani, 30, 50 
function of, 98 
perforation of, 122, 231, 

259 
ossification of, 123 
acute inflammation of, 

154 
chronic inflammation of, 

225 
specula for examining, 
228 
Meatus auditorius externus, 46 
formation of the, 114 
varieties in, 114 
absence of, 114 
how to open, 116 
acute inflammation of, 143 
chronic inflammation, 191 
erythematic chronic disease 

of, 192 
chronic inflammation of der- 
mal membrane of, 196 
treatment of, 198 
polypus, and fungus of, 200 
vegetations of, 206 
aphthse or herpetic ulcera- 
tions of, 213 
exfoliation of bone of, 214 
foreign bodies in, 215 

treatment of, 218 
auditorius interims, 66 
Modiolus, 63 

Muscles of the bones of the ear, 58 
Mucus, accumulation of, in the tym- 
panic cavities, 266, 272 

Nodal points, 90 



INDEX. 



299 



Os orbiculare or lenticulare, 56 

Ossicula auditus, 29, 32, 54 
functions of, 102-3 
when first formed, 117 
malformations of, 120 

Otalgia, 139, 254 

Otitis, 139 

acute, 139 
causes of, 140 
externa, 141 
symptoms of, 142 
treatment of, 142, 149 
erysipelatous, 145 
abscess in, 145 
common in infants, 149 

cases of, 153 
media, 157 
interna, 157 
catarrhal, 157 
purulent, 157 
varieties of, 158 
causes of, 158 
symptoms of, 160 
termination of, 162 
cases of, 163, 173 
treatment of, 173 
milder forms of, 176 
chronic external, 189 
of the auricle, 190 
of the meatus externus, 191 
interna 23.3 
danger of, 234 

Otorrhsea, chronic and purulent, 139, 
189 

Paracousis, 135 
Pinna, 42 
Pitch of sound, 95 
Portio dura, 70 

Posterior yel transversalis auris, 44 
Polypus or vegetation of the meatus, 
200 
treatment of, 203 

Sacculus vestibuli, 67 
Scala vestibuli, 64 



Scala tympani, 64 

Semicircular canals, 23, 62 

when formed, 126 

Sinus of the meatus, 207 

Sound, how propagated 76 

distance to which conveyed, 79 
rate of transmission, 79, 81 
well conducted by solids, 82 
reflection of, 83, 86 
causes producing, 88 
vibrations necessary for, 93 
loudness of, 94 

Sounds, sympathy of, 95 

Speaking-trumpet, 86 

Stapes, 56 

Tensor tympani, 58, 101 

Tragicus, 43 

Tympanum, described, 29, 50 

membrane of, 30 

use of, 33 

air in the, its office, 
104-6 

when first formed, 117 

malformations of, 119 

acute inflammation of, 
158 

chronic inflammation of, 
233 
Tympanic plexus, 73 
Tympanal otitis, 158, 233 

cases of, 163, 236 

Undulations of inflexion, 90 

Utricle, 67 

Utriculus vestibuli, absence of, 132 

Vegetations of the meatus, 206 
Vestibule described, 19, 61 

undulations through, 108 
Vidian nerve, 71 
Voice, human, imitations of, 93 

Wax in the ear, in excess, 208, 263 
treatment of, 211 
See Ceruminous Secretion. 



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